Service Contract Agreement
Download Free Print-Only PDF OR Purchase Interactive PDF Version of this Form
Service Contract Agreement Form. This is a Kentucky form and can be use in Workers Comp.
Tags: Service Contract Agreement, Kentucky Workers Comp,
This is to verify that the service contract between ____________________________________
and _____________________________________________meets the requirements set forth in
administrative regulation 803 KAR 25:021 § 3(4) and therefore contains one of the two
The service organization shall adjust to a final conclusion any and all claims that result
from an occurrence during the period for which the contract is effective unless a
substitute service organization has been procured; OR
The service organization shall adjust any and all claims for a period of sixty (60) days
following an order from the Commissioner finding the self- insured employer in default
unless a substitute service organization has been procured.
Signature of authorized Service Company Representative
Signature of authorized Self- Insured Employer Representative
American LegalNet, Inc.