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Notice of Claim Denial or Acceptance Form 111 October 2016 Edition KENTUCKY DEPARTMENT OF WORKERS’ CLAIMS Notice of Claim Denial or Acceptance Workers’ Compensation Claim No. Before ALJ: Plaintiff/Employee vs . Defendant/Employer Comes the defendant, as insured by and in response to the Application for Resolution of Claim, states as follows: ☐ 1. This claim is accepted as compensable in its entirety. ☐ 2. This claim is denied for the following reasons: ☐ (a) There is a dispute concerning the amount of compensation owed to the plaintiff. ☐ (b) Plaintiff was not employed by defendant on the date of alleged injury. ☐ (c) Plaintiff’s last injurious exposure to the risks of the occupational disease alleged did not occur in the employment of this defendant. ☐ (d) The plaintiff did not give due and timely notice to employer of the alleged occupational disease. ☐ (e) The alleged injury did not arise out of and in the course of employment. ☐ (f) Plaintiff has not contracted the occupational disease alleged. ☐ (g) The plaintiff did not give due and timely notice to employer of the injury. ☐ (h) The claim is barred by limitations. ☐ (i) Other reason for denial. 3. The following are admitted by the employer. ☐ Plaintiff’s alleged work event was covered under the Workers’ Compensation Act. ☐ The work event occurred on Date ☐ Plaintiff reported the work event on Date ☐ Plaintiff returned to work for this employer and does ☐ does not ☐ continue to work for this employer. ☐ Temporary total disability income benefits were paid as a result of the injury. ☐ Medical expenses have been paid as a result of this injury. 4. Special Answer: The Defendant/Employer for its special answers asserts the following as a bar to recovery in whole or in part in accordance with 803 KAR 25:010 Section 6(2)(d)1.: ☐ * KRS 342.035(3), unreasonable failure to follow medical advice; ☐ * KRS 342.165, safety violation, need to submit a Form SVC within 15 days; ☐ * KRS 342.316(7) or KRS 342.335, false statement on employment application; ☐ * KRS 342.395, voluntary rejection of KRS Chapter 342; ☐ * KRS 342.610(3), voluntary intoxication or self-infliction of injury; ☐ * KRS 342.710(5), refusal to accept rehabilitation services; or ☐ * Running of periods of limitations or repose under KRS 342.185, 342.270, 342.316, or other applicable statute; ☐ * Ot h e r Provide a brief summary of the basis for each special answer listed: Notice: Any person who knowingly and with intent to defraud another person, files a statement or claim containing any materially false information or conceals, for the purpose of misleading, information concerning any fact material to the action commits a fraudulent act, which is a crime. Being duly sworn, the undersigned states that the statements in this form are true and correct to the best of my knowledge and Belief. This the day of 20 . Signature Title Address Phone Number Email Address Certificate of Service I certify the original of the foregoing document was filed with the Department of Workers’ Claims, 657 Chamberlin Avenue, Frankfort, Kentucky 40601 by either U.S. Mail or electronically through the Department of Workers’ Claims Litigation Management System and copies served on the persons or entities given below: