Forms

MS Word File         

Kentucky Workers' Compensation Act Notarized Affidavit of Exemption by Building Contractor (Corporation or Partnership)

Affidavit of Building Contractor (declaring no employees) which is filed with local building permit

MS Word File

Kentucky Workers' Compensation Act Notarized Affidavit of Exemption by Building Contractor (Individual)

Affidavit of Building Contractor (declaring no employees) which is filed with local building permit office

MS Word File

Form MTR-2

Motion to Reopen KRS 342.732 Benefits

MS Word File

Form 110-CWP

Agreement as to Compensation and Order Approving Settlement for Coal Workers' Pneumoconiosis

MS Word File

Form 102-CWP

Application for Resolution of Coal Workers' Pneumoconiosis Claim

MS Word File

Educational Release Form

Authorization for Release of Educational Information

MS Word File

Form IA-1

Workers' Compensation-First Report of Injury or Illness

MS Word File

Form IA-2

Workers' Compensation-Subsequent Report

MS Word File

Form Hearing Loss Stipulation

Workers' Compensation-Hearing Loss Stipulation

MS Word File

Form Injury Stipulation

Workers' Compensation-Injury Stipulation

MS Word File

Form Occupational Disease Stipulation

Workers' Compensation-Occupational Disease Stipulation

MS Word File

Form 101

Application for Resolution of Injury Claim

MS Word File

Form 102

Application for Resolution of Occupational Disease Claim

MS Word File

Form 103

Application for Resolution of Hearing Loss Claim

MS Word File

Form 104

Plaintiff's Employment History

MS Word File

Form 105

Plaintiff's Chronological Medical History

MS Word File

Form 106

Medical Waiver and Consent Form

MS Word File

Form 107-I

Physician's Medical Report-Injury

MS Word File

Form 107-P

Physician's Medical Report-Psychological

MS Word File

Form 108-CWP

Physician's Medical Report-Occupational Disease

MS Word File

Form 108-HL

Physician's Medical Report-Hearing Loss

MS Word File

Form 108-OD

Physician's Medical Report-Occupational Disease

Form 109

Attorney Fee Election

MS Word File

Form 110-I

Agreement as to Compensation and Order Approving Settlement-Injury

MS Word File

Form 110-OD

Agreement as to Compensation and Order Approving Settlement-Occupational Disease

Form 111-I-HA

Notice of Claim Denial or Acceptance-Injury and Hearing Loss

Form 111-OD

Notice of Claim Denial or Acceptance-Occupational Disease

MS Word File

Form 112

Medical Dispute

MS Word File

Form 113

Notice of Designated Physician

MS Word File

Form 114

Request for Payment for Services or Reimbursement for Compensable Expenses

MS Word File

Form 115

Social Security Release Form

MS Word File

Form 120EX

Request for Expedited Determination of Medical Issue

Form AWW-1

Average Weekly Wage Certification

Form 150 (Excel Document)

Workers' Compensation Statistical Report

MS Word File

Form 375

Application for Split Coverage

MS Word File

Form EL1 and EL2

Employee Leasing Company Registration Form

MS Word File

Form 375 Wrap Up

Application for Split Coverage (Wrap Up)

MS Word File

Form 11

Motion to Substitute Party and Continue Benefits

MS Word File

Manual Change Form

Request for Manual Changes

MS Word File

Form 110-F

Agreement as to Compensation and Order Approving Settlement-Fatality

Form SI-01

Self-Insurers' Guarantee Agreement

MS Word File

Form SI-02

Self-Insurance Application

MS Word File

Form SI-02 Attachment

Self-Insurance Application Attachment

MS Word File

Form SI-03

Continuous Bond

MS Word File

Form SI-03 Attachment

Surety Rider

MS Word File

Form SI-04

Letter of Credit

Form SI-08

Loss Report

Managed Care - UR Form

Managed Care - UR Form

Service Contract Agreement

Service Contract Agreement

MS Word File

Form MTR-1

Motion to Reopen by Employee

MS Word File

Form MTR-3