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Notice Of Claim Denial Or Acceptance (Occupational Disease) Form. This is a Kentucky form and can be use in Workers Comp.
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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.:
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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
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