The Kentucky 101 form, officially known as the Application for Resolution of a Claim – Injury, is a crucial document for individuals seeking to resolve claims related to workplace injuries in Kentucky. This form serves as the initial step in the workers' compensation process, allowing injured employees to formally present their claims to the Kentucky Department of Workers’ Claims. Completing this form accurately and promptly is essential to ensure that claims are processed without unnecessary delays.
The Kentucky 101 form, formally known as the Application for Resolution of a Claim – Injury, is a crucial document for individuals seeking workers' compensation benefits in Kentucky. This form, issued by the Kentucky Department of Workers’ Claims, serves as the primary means for injured workers to initiate a claim process following an accident that occurred during the course of their employment. It requires detailed information about the claimant, including personal identification details, the nature of the injury, and specifics surrounding the incident, such as the date and location of the accident. Additionally, the form prompts the claimant to describe the circumstances of the injury, the body part affected, and any medical treatment received. It also addresses important considerations like whether an interpreter is needed for hearings, the status of dependents if the injured worker is deceased, and previous claims for workers’ compensation benefits. Furthermore, the form emphasizes the necessity of submitting supporting documents, such as medical reports and proof of wages, alongside the application. This comprehensive approach ensures that all relevant information is collected, facilitating a smoother resolution process for the claim.
Application for Resolution of a Claim – Injury
October 2016 Edition
KENTUCKY DEPARTMENT OF WORKERS’ CLAIMS
Application for Resolution of a Claim - Injury
Claim No.
vs.
Plaintiff
Social Security Number/ Green Card
Birth DateGender
Plaintiff Mailing Address
City/State/Postal Code
☐Outside United States
Country
Plaintiff’s Phone Number
Occupation
Filed:
Defendant/Employer (Business Name)
Defendant/ Employer Mailing Address
Insurance Carrier
Insurance Carrier Mailing Address
Additional Defendants
Additional Defendant
Mailing Address
Reason for Joinder:
I. Nature of Injury
1.Date and location of accident/injury:
Date of Injury
Location of Injury (City/State/Postal Code)
☐Plaintiff states that he/she was injured within the scope and course of employment with defendant employer on the above date at the above location.
2.Describe how the accident/injury occurred:
Cause of Injury:
3.Body part injured:
4.When and by what means did the plaintiff give notice of injury to the employer?
5.Describe medical treatment, if any:
6.Name and address (city/state/postal code) of physician whose report will be provided:
7.Will an interpreter be needed for the formal hearing? (Yes / No) If yes, in which language?
8.Dependents
Injured worker is deceased? (Yes / No)
If deceased, dependent information is required for a deceased worker. If work injury resulted in the death of claimant, attach/provide/upload Form F in addition to the application for Resolution of Claim.
9.Have you previously filed for or received workers’ compensation benefits in Kentucky? (Yes / No) If yes, please provide the following information:
Claim Number
Nature of Injury/Disease
Awards/Benefits
If not a Kentucky claim, please provide the state in which you were awarded benefits:
10.Was there concurrent employment at the time of injury? (Yes / No)
11.Name and address of concurrent employer:
Concurrent Employer Name
Concurrent Employer City
Concurrent Employer State
Postal Code
12.Has the plaintiff worked since the injury? (Yes / No)
13.Name and address of current employer and description of job currently being performed: Current Employer Name
Current Employer City
Current Employer State
Description of Job Performed:
14.Are you alleging a violation of a safety rule/regulation pursuant to KRS 342.165? (Yes / No) If yes, submit form SVC within 15 days after filing the Application for Resolution of Claim.
Attestations:
I understand that 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.
☐Plaintiff herein being duly sworn, states that the statements in this application and in Form 104, 105, and 106 to be separately filed, are true.
By entering your name below, you are confirming the accuracy of this form to the best of your knowledge.
This form prepared and submitted by
Relationship to injured worker
Submitter Phone Number
Submitter Email Address
Plaintiff Signature
Instructions for Completion of – Application for Resolution of a Claim – Injury
1.All sections of this form must be completed, and the following shall be filed within 15 days:
a.Form 104 (Plaintiff’s Employment History)
b.Form 105 (Plaintiff’s Chronological Medical History)
c.Form 106 (Medical Waiver and Consent)
d.Medical report describing and supporting the injury which is the basis of the claim.
e.Proof of Wages, including W-2’s, paycheck stubs, etc.
2.All information must be typewritten
3.File the original of this form and sufficient copies for all named defendants with the Department of Workers’ Claims, Prevention Park, 657 Chamberlin Avenue, Frankfort, Kentucky, 40601.
4.If you have no telephone number, please list a number at which you may be contacted.
5.If you have questions, call 1-800-554-8601.
Note: Special attention should be given to stating the correct name and address of the employer and insurance carrier. Otherwise, claim processing may be delayed.
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