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Motion To Reopen By Defendant Form. This is a Kentucky form and can be use in Workers Comp.
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Tags: Motion To Reopen By Defendant, MTR-3, Kentucky Workers Comp,
MTR-3
Motion to Reopen by Defendant
May 29, 1997 Edition
COMMONWEALTH OF KENTUCKY
OFFICE OF WORKERS CLAIMS
CLAIM NO. __________________
BEFORE _____________________
_____________________________
(EMPLOYEE)
PLAINTIFF
VS.
MOTION TO REOPEN
BY DEFENDANT
_____________________________
(EMPLOYER)
DEFENDANT(S)
_____________________________
(INSURANCE CARRIER)
_____________________________
(OTHER DEFENDANTS, IF APPLICABLE)
_____________________________
(SPECIAL FUND, IF APPLICABLE)
***************
The undersigned defendant moves to reopen this claim based on the following grounds
(check all that apply):
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Change of disability shown by objective medical evidence
Fraud
Mistake
Newly discovered evidence
Medical fee dispute
Conforming the award to employee’s work status for injuries after 12-12-96.
Reducing a permanent total disability award when employee returns to work.
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Explanation:
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
The undersigned further states that the following information is correct (check appropriate response):
1. __ No previous motion to reopen has been filed.
__ Previous motion to reopen filed
Month
Day
Year
On medical fee disputes:
2. __ Utilization review was done on
. A copy of the decision is attached.
(DATE)
__ Utilization review is not required because
This motion is supported by the following attached documents:
1. Affidavit(s) of ______________________________________________
(WITNESS NAMES)
2. Medical report of ____________________________________________
(DOCTOR’S NAME)
3. A current medical release Form 106 signed and witnessed.
4. A copy of the Opinion and Award, Settlement, Agreed Order, or Agreed Resolution
sought to be reopened.
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The undersigned, being duly sworn, states the foregoing statements in this motion and in Form
106 are true and accurate to the best of my knowledge and belief.
This the _______ day of _________________ 20____.
____________________________________
(DEFENDANT’S SIGNATURE)
Subscribed and sworn to before me this _______ day of _________________ 20____.
____________________________________
NOTARY PUBLIC
My Commission expires: ______________________ County: ___________________________
Respectfully submitted,
____________________________________
(DEFENDANT’S SIGNATURE)
____________________________________
(DEFENDANT’S STREET ADDRESS)
____________________________________
(DEFENDANT’S CITY/STATE/ZIP CODE)
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.
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CERTIFICATE OF SERVICE
I certify that the original was mailed to the Office of Workers Claims, Prevention Park, 657 Chamberlin
Avenue, Frankfort, Kentucky 40601 and copies of this motion and attachments were mailed to the names and
addresses of the parties given below:
Attorney for Employee if applicable: ___________________________________________
(Attorney Name or Law Firm)
___________________________________________
(Attorney Address or Law Firm Street Address)
___________________________________________
(Attorney Address, City/State/Zip)
Employee:
___________________________________________
(Employee’s Name)
___________________________________________
(Employee’s Street Address)
___________________________________________
(Employee’s City/State/Zip)
Other Parties, if applicable:
___________________________________________
(Name of Party)
___________________________________________
(Party Street Address)
___________________________________________
(Party City/State/Zip)
Special Fund, if applicable:
___________________________________________
(Special Fund)
__________________________________________
(Special Fund Street Address)
__________________________________________
(Special Fund City/State/Zip)
This _______ day of ________________, 20____.
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__________________________________________
(Defendant’s Signature)
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