FORM 104 October 2016 Edition KENTUCKY DEPARTMENT OF WORKERS' CLAIMS PLAINTIFF'S EMPLOYMENT HISTORY Name Social Security Number/Green Card Name and Address of Employer (Begin with most recent employer) Type of Industry Occupation Period of Employment Begin date End date Exposure to substances causing occupational disease (specify substance) Was an injury sustained while working for this employer? 1. 2. 3. 4. 5. 6. 7. I hereby certify that the above information is true and correct to the best of my knowledge and belief. Plaintiff's Signature Date American LegalNet, Inc. www.FormsWorkFlow.com