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Kentucky Form Center -

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Form

Description

IA-1.pdf First Report of Injury
ia-2.pdf Subsequent Report
aww1.pdf Average Weekly Wage Certification
awwcon.pdf Average Weekly Wage Certification-Concurrent
awwpost.pdf Average Weekly Wage Certification-Post Injury
11.pdf Motion to Substitute Party and Continue Benefits
fatalform.pdf Fatality Form
101.pdf Application for Resolution of Injury Claim
102.pdf Application for Resolution of Occupational Disease Claim
103.pdf Application for Resolution of Hearing Loss Claim
CHECK_LIST_FOR_PET_BRIEF.pdf Checklist for Petitioner's Brief
CHECK_LIST_FOR_RESP_BRIEF.pdf Checklist for Respondent's Brief
104.pdf Plaintiff's Employment History
105.pdf Plaintiff's Chronological Medical History
101ir.pdf Application for Resolution-Interloctory Relief
106.pdf Medical Waiver and Consent
107.pdf Medical Report-Injury/Hearing Loss/Psychological Condition
108.pdf Medical Report-Occupational Disease
109.pdf Attorney Fee Election
110-ODHLCWP.pdf Agreement as to Compensation and Order Approving Settlement-Occupational Disease/Hearing Loss
110f.pdf Agreement as to Compensation and Order Approving Settlement-Fatality
110i.pdf Agreement as to Compensation and Order Approving Settlement-Injury
111.pdf Notice of Claim Denial or Acceptance
112.pdf Medical Dispute
113.pdf Notice of Designated Physician
114.pdf Request for Payment for Services or Reimbursement for Compensable Expenses
115.pdf Social Security Release Form
120ex.pdf Request for Expedited Determination of Medical Issue
Form375.pdf Application for Split Coverage
375w.pdf Application for Split Coverage (Wrap-Up)
375e.pdf Application for Split Coverage (Employee Leasing)
el1-2.pdf Employee Leasing Company Registration Form
MTR.pdf Motion To Reopen
hls.pdf Workers' Compensation-Hearing Loss Stipulation
is.pdf Workers' Compensation-Injury Stipulation
ods.pdf Workers' Compensation-Occupational Disease Stipulation
SI01.pdf Self-Insurers' Guarantee Agreement
SI02.pdf Self-Insurance Application / Employers Application for Permission to Carry his Own Risk Without Insurance
SI02attach.pdf Self-Insurance Application Attachment - Request for Information
SI03.pdf Continuous Bond
SI03attach.pdf Surety Rider
SI04.pdf Letter of Credit
SI08.pdf Loss Report
DFWPApplication.pdf Application/Affidavit/Checklist for Certification of Kentucky Drug-Free Workplace Program Pursuant to 803 KAR 25:280
af-corp.pdf Notarized Affidavit of Exemption from the KY Workers' Compensation Act (Corporation or Partnership)
af-ind.pdf Notarized Affidavit of Exemption from the KY Workers' Compensation Act (Individual)
ManualChangeForm2009.pdf Request for Manual Change
ManagedCareUR.pdf Managed Care Utilization Review
SVC.pdf Safety Violation Alleged by Plantiff/Employee
SVE.pdf Safety Violation Alledged by Defendant/Employer
RECORDS_REQUEST_for_self_insurance.pdf Open Records Request Self Insurance Branch Copies/inspection of Self-Insurance Files
O_R_Request.pdf Open Records Request for Copies/Inspection of DWC Claim Files
ServiceContractAgreement.pdf Service Contract Agreement
Subpoena.pdf Subpoena
SubpoenaDT.pdf Subpoena Duces Tecum
Drug_free_workplace_brochure.pdf BROCHURE- Kentucky Drug Free Workplace Brochure
WorkersCompPostingNotice.pdf POSTER - Workers' Compensation Notice
2011_DWC_Guidebook.pdf BROCHURE - Workers' Compensation Guidebook