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Application For Resolution Of Coal Workers Pneumoconiosis Claim Form. This is a Kentucky form and can be use in Workers Comp.
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Tags: Application For Resolution Of Coal Workers Pneumoconiosis Claim, 102-CWP, Kentucky Workers Comp,
Form 102-CWP
Revised 6/05
KENTUCKY
OFFICE OF WORKERS' CLAIMS
Application for Resolution of Coal Workers' Pneumoconiosis Claim
Claim No. ___________________
........................................
Plaintiff
vs.
........................................
Defendant/Employer
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Social
Security Number
........................................
Street Address
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Birth
Date
........................................
City/State/Zip Code
........................................
Street Address
........................................
Insurance Carrier
......... ...............................
City/State/Zip Code
........................................
Street Address
........................................
County
........................................
City/State/Zip Code
........................................
Phone
Filed:
. . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . Other
Defendant
........................................
Street Address
........................................
City/State/Zip Code
Reason for Joinder:
............................. ..... .....
........................................
........................................
Other Defendant
........................................
Street Address
........................................
City/State/Zip Code
Reason for Joinder:
........................................
........................................
I.
1.
Nature of Occupational Disease
Plaintiff states that on the ................................ day of ....……….............................., 20..........,
(day)
(month)
(year)
he/she became affected by coal workers' pneumoconiosis arising out of and in the course of his/or
her employment.
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2.
State the date and means by which plaintiff gave notice of the injury to employer.
________________________________________________________________________
3.
Place of last exposure:___________________________________________
4.
Nature of the work in which the plaintiff was engaged at the time of exposure
________________________________________________________________________
5.
How did exposure to the disease occur? (Describe in detail)
________________________________________________________________________
(city)
(county)
(state)
II. Personal Data
6.
7.
8.
9.
Name and address of last school attended:
____________________________________
Highest grade completed in school:
__________________________________________
GED awarded: _____ yes _____no
Professional or vocational degrees, certificates, or licenses:
________________________
________________________________________________________________________
10.
Dependents:
11.
Has plaintiff previously filed a claim for Kentucky coal workers' pneumoconiosis benefits (including
retraining incentive benefits)?
___yes ___no
If yes, give the date and defendant in previous claim: ___________________________
_______________________________________________________________________
Name
Social Security Number
Relationship
III. Employment Data
12.
Weekly wage at date of last exposure: _____________________________________
Attached copy of any proof wages, such as paycheck stub, W-2, etc.
13.
Is plaintiff currently employed? ___ yes ___no
Name and address of current employer : _______________________________________
________________________________________________________________________
14.
Is plaintiff still working in an environment where he/she is exposed to the hazards of the
disease ? ____ yes ____ no
15.
Number of years of exposure to hazards of occupational disease________
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16.
Has plaintiff been exposed to the disease while working for more than one employer?
____ yes ____ no
17.
Weekly wage currently earned: _________ Attach copy of any proof of current wages.
IV. Medical Data
18.
List name and address of "B" reader whose report is attached to this Form. File original x-ray read
by this "B" reader with this form.
Name of "B" Reader
Address
19.
Are you alleging a pulmonary impairment as the result of coal dust exposure?
_____ yes ______ no
If yes, attach results of pulmonary function studies and tracings.
20.
Are you alleging a violation of a safety rule/regulation pursuant to KRS 342.165?
no_____
yes_____
Notice: Any person who knowingly and with intent to defraud any insurance company or other
person files a statement or claim containing any materially false information or conceals, for
the purpose of misleading, information concerning any fact material
thereto commits a fraudulent insurance act, which is a crime.
Plaintiff herein being duly sworn, states that the statements in this application and in Form 104, 105, and
106 are true. This the
day of _________
20____.
______________________________
Plaintiff's Signature
Subscribed and sworn to before me this
My Commission expires: __________
Prepared and submitted by:
day of
20
.
______________________________
Notary Public
County: _______________________
_______________________________
Signature of Attorney for Plaintiff
_______________________________
Name of Attorney (Print or Type)
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_______________________________
Street Address
_______________________________
City/State/Zip Code
__________________________
Telephone Number
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Instructions for
Completion of Forms 101, 102, 102-CWP and 103
Form 101 - Application for Resolution of Injury Claim
1.
All sections of this form must be completed, and must be accompanied by the following:
a.
Form 104 (Plaintiff's Employment History)
b.
Form 105 (Plaintiff's Chronological Medical History)
c.
Form 106 (Medical Waiver and Consent)
d.
Medical report describing and supporting the injury which is the basis of the claim
e.
Proof of Wages, including W-2's, paycheck stubs, etc.
2.
All information must be typewritten.
3.
File the original of this form and sufficient copies for all named defendants with the Office of Workers' Claims ,
Prevention Park, 657 Chamberlin Ave., Frankfort, Kentucky, 40601.
4.
If you have no telephone number, please list a number at which you may be contacted.
5.
If you have questions, call 1-800-554-8601.
Form 102 & Form 102-CWP - Application for Resolution of Occupational Disease Claim, and
Form 103 - Application for Resolution of Hearing Loss Claim
1.
All sections of this form must be completed, and must be accompanied by the following:
a.
Form 104 (Plaintiff's Employment History)
b.
Form 105 (Plaintiff's Chronological Medical History)
c.
Form 106 (Medical Waiver and Consent)
d.
Medical report of "B" reader supporting the disease. (Applies to 102-CWP only)
e.
Original x-ray read by "B" reader (Applies to 102-CWP only)
f.
Pulmonary function studies and tracings if a pulmonary impairment is alleged
g.
Proof of Wages, including W-2's, paycheck stubs, etc.
h.
Social Security earnings record release form
2.
This form may be filed in combination with an Application for Resolution of Injury Claim (Form 101) if both benefits
are sought. Information provided should be current through the date application is signed by plaintiff.
3.
All information must be typewritten.
4.
File the original of this form and sufficient copies for all named defendants with the Office of Workers' Claims ,
Prevention Park, 657 Chamberlin Ave., Frankfort, Kentucky, 40601.
5.
If you have questions, call 1-800-554-8601.
Note: Please list the correct name and address of the employer and insurance carrier to avoid delay in
processing the claim.
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Revised July, 2002
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