Form SVC Safety Violation Alleged by Plaintiff/Employee 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) or statute(s) alleged to have been violated by the employer: 2. State the facts as to how the alleged failure of the employer to comply with the rule(s), regulation(s) or statute(s) referred to in answers to the previous section caused or contributed to, in any degree, the accident to occur: 3. The following SVC attachments should be submitted, if applicable and available: a. Accident report b. OSHA, MSHA or other report of investigation c. Citation for safety penalty by a government agency This the day of , 20 . Submitter is: Attorney (signature) for Plaintiff/Employee or Pro Se Plaintiff 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