Form 103 Revised 6/05 KENTUCKY OFFICE OF WORKERS’ CLAIMS Application for Resolution of Hearing Loss 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.........., (day) (month) (year) he/she sustained or became disabled due to occupational hearing loss arising out of and in the course of his/or her employment. American LegalNet, Inc. www.USCourtForms.com 2. 3. Plaintiff became aware of this condition on ____________________________________ State the date and means by which plaintiff gave notice of the injury to employer. ____________________________________________________________________ ____________________________________________________________________ 4. Place of last exposure __________________________________________________ (city) (county) (state) 5. Nature of the work in which the plaintiff was engaged at the time of exposure _____ ____________________________________________________________________ 6. How did exposure to the disease occur? (Describe in detail) ____________________ ____________________________________________________________________ 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. Has plaintiff previously filed for or received workers' compensation benefits? ___yes ___no; if yes, give dates, nature of injury or disease and any award of benefits received: _______________________________________________________________ _______________________________________________________________________ Name _____no Social Security Number Relationship III. Employment Data 15. Type of work performed at date of occupational disease: __________________________ 16. Describe the physical requirements of plaintiff's customary job: _____________________ American LegalNet, Inc. www.USCourtForms.com ________________________________________________________________________ ________________________________________________________________________ 17. Weekly wage at date of occupational disease: _________________ Attach copy of any proof of wages, such as paycheck stub, W-2, etc. 18. Has plaintiff returned to work? ___ yes ___no; if yes, name and address of current employer and description of job currently being performed: ________________________ ________________________________________________________________________ 19. Is plaintiff exposed to occupational noise in his/her current job? ____ yes ____ no 20. 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 ________________________________ Street Address American LegalNet, Inc. www.USCourtForms.com ________________________________ City/State/Zip Code ________________________________ Telephone Number American LegalNet, Inc. www.USCourtForms.com 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. 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 stating the correct name and address of the employer and insurance carrier. Otherwise, claim processing may be delayed. Revised January 25, 2005 American LegalNet, Inc. www.USCourtForms.com