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Motion To Reopen By Employee Form. This is a Kentucky form and can be use in Workers Comp.
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Tags: Motion To Reopen By Employee, MTR-1, Kentucky Workers Comp,
MTR-1
Motion to Reopen by Employee
May 29, 1997 Edition
COMMONWEALTH OF KENTUCKY
OFFICE OF WORKERS CLAIMS
CLAIM NO. ______________________
BEFORE ________________________
_____________________________
(EMPLOYEE)
VS.
PLAINTIFF
MOTION TO REOPEN
BY EMPLOYEE
_____________________________
(EMPLOYER)
DEFENDANT(S)
_____________________________
(INSURANCE CARRIER)
_____________________________
(OTHER DEFENDANTS, IF APPLICABLE)
_____________________________
(SPECIAL FUND, IF APPLICABLE)
***************
The undersigned moves to reopen this claim based on the following grounds (check all that apply):
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work.
Change of disability shown by objective medical evidence
Fraud
Mistake
Newly discovered evidence
Medical dispute
Conforming the award to employees work status for injuries
after 12-12-96.
Reducing a permanent total disability award when employee returns to
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Explanation:
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
The undersigned further states that the following information is correct (check appropriate response):
1. ?
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No previous motion to reopen has been filed.
Previous motion to reopen filed
Month
Day
Year
On medical disputes:
2. ?
Utilization review was done on
. A copy of the decision is attached.
(DATE)
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Utilization review is not required because
This motion is supported by the following attached documents:
1. Affidavit(s) of ______________________________________________
(EMPLOYEE, OTHER 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____.
__________________________________________
(EMPLOYEE’S SIGNATURE)
Subscribed and sworn to before me this _______ day of _________________ 20____.
__________________________________________
NOTARY PUBLIC
My Commission expires: ____________________________ County: ____________________________
Respectfully submitted,
__________________________________________
(EMPLOYEE’S SIGNATURE)
__________________________________________
(STREET ADDRESS)
__________________________________________
(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 material
fact 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 Employer or Insurance Carrier ___________________________________________
if applicable:
(Name)
___________________________________________
(Street Address)
___________________________________________
(City/State/Zip)
Employer or Insurance Carrier:
___________________________________________
(Name)
___________________________________________
(Street Address)
___________________________________________
(City/State/Zip)
Other Parties, if applicable:
___________________________________________
(Name)
___________________________________________
(Street Address)
___________________________________________
(City/State/Zip)
Special Fund, if applicable:
___________________________________________
(Special Fund)
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___________________________________________
(Street Address)
___________________________________________
(City/State/Zip)
This _______ day of ________________, 20___.
___________________________________________
(Employee’s Signature)
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