Microsoft Word File Adobe Acrobat PDF File Description of File
PDF File​ ​Checklist for Petitioner's Brief
PDF File ​Checklist for Respondent's Brief
Form AWW1.doc ​Form AWW1.pdf ​Average Weekly Wage Certification
​FormAWWCON.doc ​FormAWWCON.pdf ​Average Weekly Wage Certification-Concurrent
FormAWWPOST.doc ​FormAWWPOST.pdf ​Average Weekly Wage Certification-Post Injury
Form F.doc ​Form F.pdf ​Fatality Form
Form 11.doc Form 11.pdf Motion to Substitute Party and Continue Benefits​
Form 101.doc Form 101.pdf ​Application for Resolution of Claim-Injury
Form 102-OD.doc ​Form 102-OD.pdf ​Application for Resolution of Claim-Occupational Disease
Form 103.doc Form 103.pdf ​Application for Resolution of Claim-Hearing Loss
Form101IR.doc ​Form101IR.pdf ​Application for Resolution-Interloctory Relief
Form 104.doc Form 104.pdf Plaintiff's Employment History​
​Form 105.doc Form 105.pdf ​Plaintiff's Chronological Medical History
Form 106.doc Form 106.pdf ​Medical Waiver and Consent Form
Form 107.doc ​Form 107.pdf Medical Report-Injury/Hearing Loss/Psychological Condition
Form 108.doc Form 108.pdf ​Medical Report-Occupational Disease
Form 109.pdf ​Attorney Fee Election
​Form 110-F.doc Form 110-F.pdf ​Agreement as to Compensation and Order Approving Settlement-Fataility
Form 110-I.doc Form 110-I.pdf ​Agreement as to Compensation and Order Approving Settlement-Injury
Form110ODHLCWP.doc Form110ODHLCWP.pdf ​Agreement as to Compensation and Order Approving Settlement-Occupational Disease/Hearing Loss
Form 111.doc Form 111.pdf ​Notice of Claim Denial or Acceptance
Form 112.doc Form 112.pdf ​Medical Dispute
Form 113.doc Form 113.pdf ​Notice of Designated Physician
Form 114.doc Form 114.pdf ​Request for Payment for Services or Reimbursement for Compensable Expenses
Form 115.doc Form 115.pdf ​Social Security Release Form
Form 120EX.doc Form 120EX.pdf ​Request for Expedited Determination of Medical Issue
Form 150.xls Form 150.pdf Workers' Compensation Statistical Report
Form 375.doc Form 375.pdf ​Application for Split Coverage
Form 375 Wrap-Up.doc Form 375 Wrap-Up.pdf ​Application for Split Coverage (Wrap Up)
Form MTR-1.doc ​Form MTR-1.pdf ​Motion to Reopen
​Form SVC.doc ​Form SVC.pdf ​Safety Violation Alleged by Plaintiff/Employee
Form SVE.doc ​Form SVE.pdf ​Safety Violation Alleged by Defendant/Employer
FormSHL.doc FormSHL.pdf ​Workers' Compensation-Hearing Loss Stipulation
FormSI.doc FormSI.pdf ​Workers' Compensation-Injury Stipulation
FormSOD.doc FormSOD.pdf ​Workers' Compensation-Occupational Disease Stipulation
​​ Requirements.pdf ​​Coverage Requirements for Employee Leasing
Form EL-1.doc Form EL-1.pdf ​Employee Leasing Company Registration Form
Form EL-2.doc Form EL-2.pdf ​Lessee Information Form
Form SI-01.doc Form SI-01.pdf ​Self-Insurers' Guarantee Agreement
Form SI-02.doc Form SI-02.pdf ​Self-Insurance Application
Form SI-02 Attachment.doc Form SI-02 Attachment.pdf ​Self-Insurance Application Attachment
Form SI-03.doc Form SI-03.pdf ​Continuous Bond
Form SI-03 Attachment.doc Form SI-03 Attachment.pdf ​Surety Rider
Form SI-04.doc Form SI-04.pdf ​Letter of Credit
Form SI-08.pdf ​Loss Report
Kentucky Drug-Free Workplace Application.doc Kentucky Drug-Free Workplace Application.pdf ​Application/Affidavit/Checklist for Certification of Kentucky Drug-Free Workplace Program Pursuant to 803 KAR 25:280
Kentucky Workers' Compensation Act Notarized Affidavit of Exemption by Building Contractor (Corporation or Partnership).doc Kentucky Workers' Compensation Act Notarized Affidavit of Exemption by Building Contractor (Corporation or Partnership).pdf ​Affidavit of Building Contractor (declaring no employees) which is filed with local building permit.
Kentucky Workers' Compensation Act Notarized Affidavit of Exemption by Building Contractor (Individual).doc Kentucky Workers' Compensation Act Notarized Affidavit of Exemption by Building Contractor (Individual).pdf ​Affidavit of Building Contractor (declaring no employees) which is filed with local building permit.
Managed Care-UR Form.doc Managed Care-UR Form.pdf ​Managed Care-UR Form
Open Records Request Form.doc Open Records Request Form.pdf ​Request for copies/inspection of DWC claim files.
Service Contract Agreement.doc Service Contract Agreement.pdf ​Service Contract Agreement
Self-Insurance Open Records Request Form.doc Self-Insurance Open Records Request Form.pdf ​Request for copies/inspection of Self-Insurance files.
Subpoena.doc Subpoena.pdf ​Subpoena
Subpoena Duces Tecum.doc Subpoena Duces Tecum.pdf ​Subpoena Duces Tecum
Workers' Compensation Posting Notice.doc Workers' Compensation Posting Notice.pdf ​Workers' Compensation Posting Notice

 

To request a Form 4 (Notice of Rejection) or Form 5 (Written Notice of Withdrawal), email Compliance Branch at LaborKYWCCompliance@ky.gov.  Please provide the Business Name, Contact Name, Mailing Address, Phone Number, and Number of Requested Forms.



 
 
 
 
 
 
 
 
 
 
Department of Workers' Claims
657 Chamberlin Avenue
Frankfort KY  40601
Phone: (502) 564-5550
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