Form SVE Safety Violation Alleged by Defendant/Employer October 2016 Edition KENTUCKY DEPARTMENT OF WORKERS222 CLAIMS Frankfort, KY 40601 Workers222 Compensation Claim No. IF THIS FORM IS NOT PROPERLY COMPLETED, IT WILL BE RETURNED. Every section should be filled in. If a section is not applicable, fill in the blank with N/A. Plaintiff/Employee Defendant/Employer 1. For the alleged safety violation pursuant to KRS 342.165, state the safety rule(s), regulation(s), statute(s), or orders the employee is alleged to have failed to follow or obey: 2. If it is to be alleged the employee intentionally failed to use a safety appliance furnished by the employer, state the safety appliance (if not, state 223N/A224): 3. State the facts as to how the alleged failure by the employee to use a safety appliance furnished by the employer or to obey a safety rule, regulation, statute or order caused, in any degree, the accident to occur. 4 . The following SVE attachments should be submitted, if applicable and available: a. Accident report b. OSHA, MSHA or other report of investigation c. Any safety manual, employee handbook or other document provided to the employee by the employer relative to the use of the subject safety appliance, rule, regulation, statute, or order This the day of , 20 . Submitter is: At torney (signature) for Defendant/Employer American LegalNet, Inc. www.FormsWorkFlow.com Certificate of Service I certify the original of the foregoing document was filed with the Department of Workers222 Claims, 657 Chamberlin Avenue, Frankfort, Kentucky 40601 by either U.S. Mail or electronically through the Department of Workers222 Claims Litigation Management System and copies served on the persons or entities given below: American LegalNet, Inc. www.FormsWorkFlow.com