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 AWW.pdf ​Average Weekly Wage Certification
Form 11.doc Form 11.pdf Motion to Substitute Party and Continue Benefits​
Form 101.doc Form 101.pdf ​Application for Resolution of Injury Claim
Form 102-OD.doc Form 102-OD.pdf ​Application for Resolution of Occupational Disease Claim
Form 102-CWP.doc Form 102-CWP.pdf ​Application for Resolution of Coal Workers' Pneumoconiosis Claim
Form 103.doc Form 103.pdf ​Application for Resolution of Hearing Loss Claim
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-I.doc Form 107-I.pdf ​Physician's Medical Report-Injury
Form 107-P.doc Form 107-P.pdf

​Physician's Medical Report-Psychological

Form 108-CWP.doc Form 108-CWP.pdf ​Physician's Medical Report-Occupational Disease
Form 108-HL.doc Form 108-HL.pdf ​Physician's Medical Report-Hearing Loss
Form 108-OD.doc Form 108-OD.pdf ​Physician's Medical Report-Occupational Disease
Form 109.pdf ​Attorney Fee Election
Form 110-CWP.doc Form 110-CWP.pdf ​Agreement as to Compensation and Order Approving Settlement for Coal Workers' Pneumoconiosis
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
Form 110-OD.doc Form 110-OD.pdf ​Agreement as to Compensation and Order Approving Settlement-Occupational Disease
Form 111-I-HL.doc Form 111-I-HL.pdf ​Notice of Claim Denial or Acceptance-Injury and Hearing Loss
Form 111-OD.doc Form 111-OD.pdf ​Notice of Claim Denial or Acceptance-Occupational Disease
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 EL1 & EL2.doc Form EL1 & EL2.pdf

​Employee Leasing Company Registration Form

Form MTR-1.doc Form MTR-1.pdf ​Motion to Reopen by Employee
Form MTR-2.doc Form MTR-2.pdf ​Motion to Reopen KRS 342.732 Benefits
Form MTR-3.doc Form MTR-3.pdf ​Motion to Reopen by Defendant
Form NMRP.doc Form NMRP.pdf ​Notice of Filing Medical Report
Form Hearing Loss Stipulation.doc Form Hearing Loss Stipulation.pdf ​Workers' Compensation-Hearing Loss Stipulation
Form Injury Stipulation.doc Form Injury Stipulation.pdf ​Workers' Compensation-Injury Stipulation
Form Occupational Disease Stipulation.doc Form Occupational Disease Stipulation.pdf ​Workers' Compensation-Occupational Disease Stipulation
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
IA-1.pdf ​IAIABC First Report of Injury Form
IA-2.pdf  ​IAIABC Subsequent Report of Injury Form
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
MIR-1.doc MIR-1.pdf ​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.'
MIR-2.doc MIR-2.pdf ​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.'
MIR-3.doc MIR-3.pdf ​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.'
MIR-4.doc MIR-4.pdf ​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.'
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

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To request a Form 4 - Notice of Rejection or Form 5 - Written Notice of Withdrawal (rev.5/2000), please contact Linda Bramham at 502-782-4412.



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