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Motion To Substitute Party And Continue Benefits Form. This is a Kentucky form and can be use in Workers Comp.
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Tags: Motion To Substitute Party And Continue Benefits, 11, Kentucky Workers Comp,
Form 11
Effective 1/31/2005
KENTUCKY OFFICE OF WORKERS’ CLAIMS
657 Chamberlin Avenue
Frankfort, KY 40601
Workers’ Compensation Claim no. __________________
Motion to Substitute Party and Continue Benefits
Come now the undersigned, being all dependents of the deceased Plaintiff, __________________
and hereby move to be substituted as the Plaintiff herein for the purpose of receipt of benefits, and further
state as follows:
1. Employee/Plaintiff:_________________________________________SSN:____________________
2.
Date of death (attach copy of certified Death Certificate):___________________________________
3.
Cause of death: ____________________________________________________________________
4.
Date of Award/Settlement and amount: _________________________________________________
5.
Name and address of party paying benefits:______________________________________________
6.
Date of Marriage (attach copy of certified Marriage License): _______________________________
7.
List of dependent(s) (attach copies of certified Birth Certificates):
NAME
SOCIAL
SECURITY NO.
DATE OF
BIRTH
RELATIONSHIP
ADDRESS (city, state, zip code)
Wherefore, the dependent(s) request that he/she (they) be substituted as the Plaintiff and that said
benefits be paid directly to him/her (them).
The undersigned hereby states that the foregoing is true and accurate to the best of my knowledge
and belief.
Respectfully submitted,
_______________________________________
(Signature)
_______________________________________
Address
_______________________________________
Relationship to decedent
Subscribed and sworn to before me by ______________________ on this __________ day of
____________________, 20____.
________________________________
Notary Public, Kentucky, State at Large
My commission expires: ____________
I certify that copies were mailed this _________ day of ____________, 20______ to:
Employer or Attorney for Employer: _________________________________________
Other Parties (if applicable): ___ ____________________________________________
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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