Notice Of Claim Denial Or Acceptance (Occupational Disease) Form. This is a Kentucky form and can be use in Workers Comp.
Tags: Notice Of Claim Denial Or Acceptance (Occupational Disease), 111-OD, Kentucky Workers Comp,
COURT COUNTY .OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ......... .. : Notice of Claim Denial or Acceptance Form 111- OD Adopted 1/1/97 : Index No. Calendar No. Filed: COMMONWEALTH OF KENTUCKY : DEPARTMENT OF Plaintiff(s) WORKERS CLAIMS JUDICIAL SUBPOENA Before Arbitrator -against: Claim Number NOTICE OF CLAIM DENIAL OR ACCEPTANCE Do Not Write In This Space : : Plaintiff/Employee Defendant(s) : ...................................................... vs. Defendant/Employer THE Comes the defendant, PEOPLE OF THE STATE OF NEW YORK , as insured by response to the Application for Resolution of Claim, states as follows: , and in TO 1. This claim is accepted as compensable in its entirety. A settlement agreement will be filed. (Note: if claim is accepted, do not complete paragraphs 2 - 7). GREETINGS: 2. This claim is accepted as compensable, but there is a dispute concerning the amount of WEcompensationYOU, thatthe business and excuses being laid aside, you and each of you attend before COMMAND owed to all plaintiff. , the Honorable at the Court for the following reasons: County3. of This claim is deniedlocated at in room , on the day of , 20 , at o'clock in the noon, and at any recessed (a) testify and give evidence as a witness the risks of on occupational or adjourned date, to Plaintiff's last injurious exposure to in this action the the part of the disease alleged did not occur in the employment of this defendant. Explain: Your failure to comply with this subpoena is punishable as a contempt of court and will make you liable to (b) The this subpoena was issued and maximum penalty of $50 and all the party on whose behalfplaintiff did not give due for atimely notice to employer of the damages sustained as a result of your failure alleged occupational disease. to comply. Explain: Witness, Honorable (c) The claim is barred by limitations. Court in County, day of , 20 , one of the Justices of the Explain: (d) Plaintiff has not contracted the occupational disease alleged. (Attorney must sign above and type name below) Explain: Other reason for denial. Explain: 4. Attorney(s) for The plaintiff's average weekly wage at the time of the alleged exposure was $ Completed AWW-1 to support this calculation is attached. . Office and P.O. Address 5. The following witnesses may present testimony relevant to denial of this claim. 1. Telephone No.: 2. Facsimile No.: 3. E-Mail Address: 4. Mobile Tel. No.: American LegalNet, Inc. www.USCourtForms.com COURT COUNTY .OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . .. 6. . . . . .The. following are admitted by the employer: : Yes No Index No. This claim is covered by the Workers Compensation Act. : Calendar No. : Plaintiff was an employee of this defendant on the date alleged in the JUDICIAL SUBPOENA Plaintiff(s) Application for Resolution of Claim. -against- : Plaintiff was exposed to the hazards of the disease during employment by : more than one employer. : Plaintiff has returned to work for this employer and is earning $______ per week. Defendant(s) : .. ...... .......... ....... .... ... ........... 7. . . . . .For. alleged .occupational. diseases .other.than. coal workers' pneumoconiosis, describe in detail the physical requirements of plaintiff's job on the alleged date of last exposure. If an official job description exists, a copy must be attached. THE PEOPLE OF THE STATE OF NEW YORK 8. The following persons have gathered information for completion of this form. TO For the employer: Name GREETINGS: Title Address Street WE COMMAND YOU, that all business and excuses being laid aside, you and each of you attend before City State Zip Code , the Honorable at the Court (located at ) County of Telephone Number in room , on the day of , 20 , at o'clock in the noon, and at any recessed or adjourned date, to testify and give evidence as a witness in this action on the part of the For the insurance carrier: Name Title Your failure to comply with this subpoena is punishable as a contempt of court and will make you liable to Address Street the party on whose behalf this subpoena was issued for a maximum penalty of $50 and all damages sustained as a result of your failure to comply. City Witness, Honorable Court in County, State Zip Code ( ) Telephone Number , one of the Justices of the day of , 20 Being duly sworn, the undersigned states that the statements in this form are true and correct to the best day of , 200 . of my knowledge and belief. This the (Attorney must sign above and type name below) Signature Title Attorney(s) for Address Phone Number Subscribed and sworn to before me this My commission expires: County: day of , 200 Office and P.O. Address Notary Public Prepared and submitted by: Representative/Title Address Telephone No.: Facsimile No.: E-Mail Address: Mobile Tel. No.: Phone Number American LegalNet, Inc. www.USCourtForms.com