The Kentucky 5 form is a written notice of withdrawal used by employees to retract their previous notice of rejection regarding workers' compensation claims. This form is essential for individuals wishing to be covered under the Kentucky Workers' Compensation Act after initially declining coverage. Proper completion and submission of the form ensure that the withdrawal is officially recognized by the employer and the Department of Workers Claims.
The Kentucky 5 form, also known as the Written Notice of Withdrawal, serves a crucial role in the workers' compensation process within the state. This form allows employees to formally withdraw their previous notice of rejection regarding workers' compensation benefits. By completing this document, an employee indicates their desire to be covered under the Kentucky Workers’ Compensation Act, as outlined in the Kentucky Revised Statutes Chapter 342. The form requires specific information, including the employer's details, such as their federal ID number, name, and contact information, as well as the employee's name and social security number. Additionally, it includes sections for the effective date of withdrawal and the date the original rejection notice was filed. Notably, the withdrawal will not take effect for any injury or disease sustained less than one week after the notice is submitted to the employer. To ensure proper processing, employers are responsible for filing the original form with the Department of Workers Claims, and employees are encouraged to request acknowledgment of receipt. By understanding the Kentucky 5 form and its requirements, both employees and employers can navigate the complexities of workers' compensation more effectively.
FORM NO. 5
WRITTEN NOTICE OF WITHDRAWAL (REV. 7/97)
DEPARTMENT OF WORKERS CLAIMS
1270 LOUISVILLE ROAD
FRANKFORT, KENTUCKY 40601
WRITTEN NOTICE OF WITHDRAWAL OF FORM 4 REJECTION
EMPLOYER DATA:
FEDERAL ID# _____________________________
EMPLOYER NAME ____________________________________________________ PHONE NO. ________________________
STREET ADDRESS __________________________________________________________________________________________
CITY, STATE, ZIP ___________________________________________________________________________________________
NATURE OF BUSINESS ____________________________________
#OF EMPLOYEES ________________________________
EMPLOYEE DATA:
NAME ______________________________________ SOCIAL SECURITY NUMBER _________________________________
STREET ADDRESS ______________________________________________ EMPLOYEE PHONE NO. ____________________
I HEREBY WISH TO NOTIFY THE ABOVE LISTED EMPLOYER THAT I WISH TO WITHDRAW MY EMPLOYEE’S WRITTEN NOTICE OF REJECTION EFFECTIVE__________________________. THE REJECTION NOTICE WAS FILED WITH THE DEPARTMENT OF WORKERS
CLAIMS ON OR ABOUT_________ (YEAR). I NOW WISH TO BE COVERED UNDER THE PROVISIONS OF THE KENTUCKY REVISED
STATUTES CHAPTER 342, COMMONLY KNOWN AS THE WORKERS’ COMPENSATION ACT. I HAVE FILED THIS FORM WITH MY EMPLOYER ON THIS DATE.
_____________________________________________________________
EMPLOYEE SIGNATURE
DATE
STATE OF ______________________
COUNTY OF ____________________
SUBSCRIBED AND SWORN TO BEFORE ME BY ___________________________________________________ TO BE
EMPLOYEE NAME
HIS/HER VOLUNTARY ACT AND DEED, ON THIS______________DAY OF______________________________ , _________.
____________________________________
________________________________________
NOTARY PUBLIC
MY COMMISSION EXPIRES:
ACKNOWLEDGMENT OF RECEIPT AND FILING
I,_______________________________________________________HEREBY ACKNOWLEDGE THAT THE ABOVE-MENTIONED EMPLOYEE
FILED THIS WITHDRAWAL OF THE NOTICE OF REJECTION WITH HIS/HER EMPLOYER ON THE __________________________DAY OF
_________________, _________, AND THAT THE ORIGINAL OF THIS FORM WAS MAILED TO THE DEPARTMENT OF WORKERS CLAIMS
ON THIS DATE.
BY: ___________________________________________________________________________
EMPLOYER
TITLE
INSTRUCTIONS FOR WITHDRAWAL OF
EMPLOYEE’S WRITTEN NOTICE OF REJECTION
Pursuant to KRS 342.395(3), withdrawal of the notice of rejection shall not be effective as to any injury sustained or disease incurred less than one (1) week after notice is filed with the employer.
The employer must file the original of this form with the Department of Workers Claims. Forms should be mailed to: Department of Workers Claims, ATTENTION: Enforcement
Branch, 1270 Louisville Road, Frankfort, Kentucky 40601.
If you want to have the filing of the withdrawal acknowledged by the Department, you must forward with the original, a photostatic copy and a self-addressed stamped envelope.
If you have any questions, please contact the Enforcement Branch at (800) 731-5241.
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