Form 101 Revised 6/05 KENTUCKY OFFICE OF WORKERS’ CLAIMS Application for Resolution of Injury 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 Number . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . Other Defendant Filed: ........................................ Street Address ........................................ City/State/Zip Code Reason for Joinder: ............................. ..... ..... ........................................ ........................................ Other Defendant ........................................ Street Address ........................................ City/State/Zip Code Reason for Joinder: ........................................ ........................................ I. Nature of Injury 1. Plaintiff states that on the day of 20 , he/she was injured within the scope and course of employment with defendant employer at____________________ ________________________________________________________________________ (City/County/State) American LegalNet, Inc. www.USCourtForms.com 2. Describe how the injury occurred:____________________________________________ _______________________________________________________________________ _______________________________________________________________________ 3. Body part injured: ________________________________________________________ 4. State the date and means by which the plaintiff gave notice of injury to the employer: _______________________________________________________________________ _______________________________________________________________________ 5. Describe medical treatment, if any:___________________________________________ _______________________________________________________________________ _______________________________________________________________________ 6. Name and address of physician whose report is attached:__________________________ _______________________________________________________________________ II. Personal Data 7. Name and address of last school attended: _____________________________________ _______________________________________________________________________ 8. Highest grade completed in school:____________ 9. GED awarded: _____ yes 10. Professional or vocational degrees, certificates, or licenses: ________________________ ________________________________________________________________________ 11. Dependents: 12. Have you previously filed for or received workers' compensation benefits? ___yes ___no Name _____no Date of Birth Social Security Number Relationship If yes, give Office of Workers’ Claims file number(s), dates and nature of injury or disease and any award of benefits received; ___________________________________________ ________________________________________________________________________ American LegalNet, Inc. www.USCourtForms.com III. Employment Data 13. Is plaintiff currently working? ______ yes ______ no 14. Type of work performed at date of injury: ______________________________________ ______________________________________________________________________________ 15. Describe the physical requirements of job performed at date of injury: _______________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ 16. Weekly wage at date of injury: _________________. Attach copy of any proof of wages, such as paycheck stub, W-2, etc. 17. Weekly wage currently earned:_________ Attach copy of any proof of current wages. 18. Name and address of current employer and description of job currently being performed: ______________________________________________________________________________ _______________________________________________________________________________ 19. Are you alleging a violation of a safety rule/regulation pursuant to KRS 342.165? yes______ no______ 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 day of 20 . ______________________________ Notary Public My Commission expires: __________ County: ___________ Prepared and submitted by: ________________________________ Signature/Representative for Plaintiff _________________________________ Title American LegalNet, Inc. www.USCourtForms.com _________________________________ Street Address _________________________________ City/State/Zip ________________________________ Telephone Number Instructions for Completion of Forms 101, 102 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 Avenue, 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 - 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 supporting the occupational disease e. Proof of Wages, including W-2's, paycheck stubs, etc. f. 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. American LegalNet, Inc. www.USCourtForms.com 4. File the original of this form and sufficient copies for all named defendants with the Office of Workers’ Claims, Prevention Park, 657 Chamberlin Avenue, Frankfort, Kentucky, 40601. 5. If you have questions, call 1-800-554-8601 Note: Special attention should be given to s tating the correct name and address of the employer and insurance carrier. Otherwise, claim processing may be delayed. Revised American LegalNet, Inc. www.USCourtForms.com