If you are seeing or hearing this, then either your browser/user agent does not support Cascading Style Sheets, or you have elected to turn them off.  You may see and/or hear immediately following this notice alerts regarding national security or the Amber Alert system that do not apply.  To see if these alerts apply, follow the links provided.  -Commonwealth of Kentucky
The national Homeland Security Advisory System's Threat Condition is currently red, meaning severe.  Check your local radio or television stations for up-to-date information.  You may also check the National Homeland Security website or the Kentucky Homeland Security website for more information.  -Commonwealth of Kentucky
The national Homeland Security Advisory System's Threat Condition is currently orange, meaning high.  Check your local radio or television stations for up-to-date information, or you may visit the National Homeland Security website or the Kentucky Homeland Security website for more information.  -Commonwealth of Kentucky
An Amber Alert has been issued.  Visit the Kentucky Emergency Management website for information.  -Commonwealth of Kentucky
Logo for the Kentucky.gov site. By clicking this logo, you will be taken to the Kentucky state home page. KY Agencies| KY Services  
www.labor.ky.gov Logo
  US Department of Labor | KOSH Review Commission | Kentucky Workers' Compensation Funding Commission | Site Map
  Kentucky Labor Cabinet>  Department of Workers' Claims
Kentucky Unbridled Spirit-External Site
Department of Workers' Claims |
Claims Processing |
Communications Network |
Constituent Services (Specialists - Ombudsmen) |
EDI |
Forms |
Hearing Locations |
Information and Research |
Key Personnel And Organizational Breakdown |
Managed Care Reporting Requirements |
Medical Services and Cost Containment |
Other Links |
Publications |
Request a Speaker |
Research and Statistics |
Security and Compliance |
Statutes and Regulations |
Workers’ Compensation Board

Get Adobe Reader
Last Modified:  10/24/2009
Forms
 
Forms
Microsoft Word File Adobe Acrobat PDF File Description of File
Form AWW-1 Average Weekly Wage Certification
MS Word File Form 11 Motion to Substitute Party and Continue Benefits
MS Word File Form 101 Application for Resolution of Injury Claim
MS Word File Form 102-OD Application for Resolution of Occupational Disease Claim
MS Word File Form 102-CWP Application for Resolution of Coal Workers' Pneumoconiosis 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-CWP Agreement as to Compensation and Order Approving Settlement for Coal Workers' Pneumoconiosis
MS Word File Form 110-F Agreement as to Compensation and Order Approving Settlement-Fatility
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-HL Notice of Claim Denial or Acceptance-Injury and Hearing Loss
Form 111-OD Notice of Claim Denial or Accpetance-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 150 (Excel document) Workers' Compensation Statistical Report
MS Word File Form 375 Application for Split Coverage
MS Word File Form 375 Wrap-Up Application for Split Coverage (Wrap Up)
MS Word File Form EL1 & EL2 Employee Leasing Company Registration Form
MS Word File Form MTR-1 Motion to Reopen by Employee
MS Word File Form MTR-2 Motion to Reopen KRS 342.732 Benefits
MS Word File Form MTR-3 Motion to Reopen by Defendant
MS Word File Form NMRP Notice of Filing Medical 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
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
MS Word File Kentucky Drug-Free Workplace Application Application/Affidavit/Checklist for Certification of Kentucky Drug-Free Workplace Program Pursuant to 803 KAR 25:280
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.
MS Word File Manual Change Form Request for EDI Manual Changes (By Carrier or TPA)
MS Word File Managed Care - UR Form Manged Care - UR Form
MS Word File MIR-1 Motion for Interlocutory Relief 'If you are attempting to fill out this form without counsel, you may contact a workers' compensation specialist for assistance toll free at 800-554-8601.'
MS Word File MIR-2 Affidavit for Payment of Medical Expenses 'If you are attempting to fill out this form without counsel, you may contact a workers' compensation specialist for assistance toll free at 800-554-8601.'
MS Word File MIR-3 Affidavit for Payment of Temporary Total Disability 'If you are attempting to fill out this form without counsel, you may contact a workers' compensation specialist for assistance toll free at 800-554-8601.'
MS Word File MIR-4 Affidavit Regarding Rehabilitation Services 'If you are attempting to fill out this form without counsel, you may contact a workers' compensation specialist for assistance toll free at 800-554-8601.'
Service Contract Agreement Service Contract Agreement

The IA-1 and IA-2 Forms can be obtained from the IAIABC website: http://www.iaiabc.org/.  From the EDI drop down tab, choose EDI Standard Forms, Codes and Resources.  The forms are near the bottom of the page.

To request a Form 4 (rev. 5/2000), please contact Jim Mitchell at 502-564-5550, ext. 4490.
Department of Workers' Claims
657 Chamberlin Avenue
Frankfort KY 40601
Phone: 502-564-5550 ext 4578
E-mail: Department of Workers' Claims
Feedback: LaborWebmaster | About the Agency | About this Site
Privacy | Disclaimer | Individuals with Disabilities | Resources