Motion to Reopen Form MTR October 2016 Edition COMMONWEALTH OF KENTUCKY DEPARTMENT OF WORKERS222 CLAIMS Workers222 Compensation Claim No. PLAINTIFF/EMPLOYEE VS. MOTION TO REOPEN DEFENDANT/EMPLOYER The undersigned moves to reopen this claim based on the following grounds ( check all that apply) : Change of Disability shown by objective medical evidence Fraud Mistake Newly Discovered evidence Conforming the award to employee222s work status for injuries after 12-12-96 Reducing a permanent total disability award when employee returns to work (To reopen for a medical dispute, please file a Form 112 Medical Dispute for re-opening a claim.) Explanation: Have you previously filed a motion to reopen? Yes No Date of previous motion to reopen: NOTE: Pursuant to KRS 342.125(3) no party may file a motion to reopen within one (1) year of any previous motion to reopen by the same party. American LegalNet, Inc. www.FormsWorkFlow.com This motion is supported by the following attached documents: Affidavit(s) of employee / other witnesses Medical report A current medical release Form 106, signed and witnessed A c opy of the Opinion and Aw a rd, Settl e ment, A g r e e d O r d e r, or A g r e e d R e solu t ion sou g ht t o be r e op e n e d Utilization review The und e rsi g n e d, b e ing duly swo r n, st a tes the fo r e g oing stat e ments in th i s mo t ion a nd in F orm 106 a re true and accurate to the best of my knowledge and belief. This the day of 20 . Respectfully submitted, Signature Mailing Address City/State/Postal Code Submitter Phone Number Submitter Email Address No t ic e : Any p er son w h o kn o w i n gly a n d w ith i n t e n t t o d e f r a u d a n y i n s u r a n c e c o m p a n y or other person files a statement or claim containing any materially false information or conceals, for the purpose of misleading, information concerning any material fact commits a fraudulent insurance act, which is a crime. American LegalNet, Inc. www.FormsWorkFlow.com CERTIFICATE OF SERVICE I certify that the original was mailed to the Department of Workers222 Claims, 657 Chamberlin Avenue, Frankfort, Kentucky 40601 or filed and served electronically through the Department of Workers222 Claims Litigation Management System to the Department of Workers222 Claims and copies of this motion and attachments were served on the names and addresses of the parties below: Attorney for Employer or Insurance Carrier if applicable: (Name) (Mailing Address) (City/State/Postal Code) Employer or Insurance Carrier : (Name) (Mailing Address) (City/State/Postal Code) Other Parties, if applicable: (Name) (Mailing Address) (City/State/Postal Code) Special Fund, if applicable: (Name) (Mailing Address) (City/State/Postal Code) American LegalNet, Inc. www.FormsWorkFlow.com