Form 11 October 2016 Edition KENTUCKY DEPARTMENT OF WORKERS222 CLAIMS 657 Chamberlin Avenue, Frankfort, KY 40601 Claim No. Before Request to Substitute Party and Continue Benefits The undersigned, being a dependent of the deceased plaintiff/employee, requests to be substituted as the plaintiff/employee for the purpose of receipt of benefits, and further states as follows: 1. Employee/Plaintiff: SSN/Green Card: 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) requesting substitution (attach copies of certified Birth Certificates): NAME SSN/GREEN CARD DATE OF BIRTH RELATIONSHIP ADDRESS (mailing address, city, state, postal code) Is decedent/employee survived by any minor dependents other than those listed above? Yes No If yes, please list below: Name Mailing Address, City, State, Postal Code Date of Birth Guardian/Custodian American LegalNet, Inc. www.FormsWorkFlow.com Wherefore, the dependent requests that he/she be substituted as the Plaintiff/Employee and that said benefits be paid directly to him/her. The undersigned hereby states that the foregoing is true and accurate to the best of my knowledge and belief and so attests under penalty of perjury. Respectfully submitted, Signature Mailing Address Relationship to Decedent City/State/Postal Code Phone Number Country Email Address I certify that copies were served this day of , 20 on : Defendant/Employer Attorney for Defendant/Employer Defendant/ Employer Mailing Address Attorney for Defendant/Employer Mailing Address Defendant/Employer City/State/Postal Code Attorney for Defendant/Employer City/State/ Postal Code 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. American LegalNet, Inc. www.FormsWorkFlow.com