Commonwealth of Kentucky Labor Cabinet

Coming Soon - the new Education and Labor Cabinet website at kelc.ky.gov

Forms, Documents, Reports, Publications and Archives

Forms

Address Change Request Form [pdf, 168KB]
Workers' Comp/Home/Forms
Administrative Law Judge Application Supplement 2021 [pdf, 375KB]
Workers' Comp/Workers' Claims/Forms
Administrative Law Judge Application Supplement 2022 [pdf, 125KB]
Workers' Comp/Workers' Claims/Forms
AFFIDAVIT OF EXEMPTION (Corp.) [pdf, 63KB]
Workers' Comp/Compliance/Forms
AFFIDAVIT OF EXEMPTION (Indiv.) [pdf, 63KB]
Workers' Comp/Compliance/Forms
Agreement as to Compensation and Order Approving Settlement-Fataility(Form 110F) [pdf, 140KB]
Workers' Comp/Workers' Claims/Forms
Agreement as to Compensation and Order Approving Settlement-Fataility(Form 110F) [docx, 122KB]
Workers' Comp/Workers' Claims/Forms
Agreement as to Compensation and Order Approving Settlement-Injury(Form 110I) [pdf, 261KB]
Workers' Comp/Workers' Claims/Forms
Agreement as to Compensation and Order Approving Settlement-Injury(Form 110I) [docx, 38KB]
Workers' Comp/Workers' Claims/Forms
Agreement as to Compensation and Order Approving Settlement-Occupational Disease/Hearing Loss(Form 110ODHLCWP) [pdf, 264KB]
Workers' Comp/Workers' Claims/Forms
Agreement as to Compensation and Order Approving Settlement-Occupational Disease/Hearing Loss(Form 110ODHLCWP) [docx, 38KB]
Workers' Comp/Workers' Claims/Forms
APPLICATION FOR CONTINUATION OF MEDICAL BENEFITS (10-4-18 rev) [pdf, 250KB]
Workers' Comp/Workers' Claims/Forms; Document
APPLICATION FOR CONTINUATION OF MEDICAL BENEFITS (10-4-18 rev) [docx, 76KB]
Workers' Comp/Workers' Claims/Forms
Application for Resolution of a Claim [docx, 109KB]
Workers' Comp/Workers' Claims/Forms
Application for Resolution of a Claim - Hearing Loss [pdf, 171KB]
Workers' Comp/Workers' Claims/Claims; Document; Forms
Application for Resolution of a Claim - Hearing Loss [docx, 120KB]
Workers' Comp/Workers' Claims/Forms
Application for Resolution of a Claim - Injury [pdf, 154KB]
Workers' Comp/Workers' Claims/Claims; Forms
Application for Resolution of a Claim - Interlocutory Relief [docx, 27KB]
Workers' Comp/Workers' Claims/Claims; Forms
Application for Resolution of a Claim - Interlocutory Relief [pdf, 133KB]
Workers' Comp/Home/Forms
Application for Resolution of a Claim - Occupational Disease [pdf, 167KB]
Workers' Comp/Workers' Claims/Claims; Forms
Application for Resolution of a Claim - Occupational Disease [docx, 114KB]
Workers' Comp/Workers' Claims/Forms
Application for Resolution-Interloctory Relief [pdf, 135KB]
Workers' Comp/Workers' Claims/Forms
Application for Split Coverage or Wrap Up (Form 375) [pdf, 415KB]
Workers' Comp/Compliance/Forms
Attorney Fee Election [pdf, 25KB]
Workers' Comp/Home/Forms
Average Weekly Wage Certification [pdf, 72KB]
Workers' Comp/Home/Forms
Average Weekly Wage Certification AWW-1 [pdf, 18KB]
Workers' Comp/Home/Forms
Average Weekly Wage Certification-Concurrent [pdf, 72KB]
Workers' Comp/Home/Forms
Average Weekly Wage Certification-Post Injury [pdf, 73KB]
Workers' Comp/Home/Forms
Certification of Coverage Request [pdf, 103KB]
Workers' Comp/Compliance/Forms
CHANGE OF ADDRESS FOR CONTINUATION OF MEDICAL BENEFITS (10-4-18 rev) [pdf, 252KB]
Workers' Comp/Workers' Claims/Document; Forms
CHANGE OF ADDRESS FOR CONTINUATION OF MEDICAL BENEFITS (10-4-18 rev) [docx, 76KB]
Workers' Comp/Workers' Claims/Forms
DHLSForm [doc, 47KB]
Workers' Comp/Home/Forms
DHLSForm [pdf, 16KB]
Workers' Comp/Home/Forms
Direct Deposit Form [pdf, 171KB]
Workers' Comp/Home/Forms
DISForm [doc, 47KB]
Workers' Comp/Home/Forms
DISForm [pdf, 16KB]
Workers' Comp/Home/Forms
DODSForm [doc, 47KB]
Workers' Comp/Home/Forms
DODSForm [pdf, 15KB]
Workers' Comp/Home/Forms
EDIVEN-1 Revised 8-10-2021 [pdf, 106KB]
Workers' Comp/Workers' Claims/Forms; EDI
Employee Leasing Application (Form EL1 and EL2) [pdf, 131KB]
Workers' Comp/Compliance/Forms
Fatality Form [pdf, 121KB]
Workers' Comp/Workers' Claims/Forms
Form 104 [docx, 24KB]
Workers' Comp/Home/Forms
Form 105 [docx, 24KB]
Workers' Comp/Home/Forms
Form 106 [doc, 43KB]
Workers' Comp/Home/Forms
Form 108 [pdf, 166KB]
Workers' Comp/Workers' Claims/Forms
Form 108 [docx, 128KB]
Workers' Comp/Workers' Claims/Forms
FORM 108 - CWP [doc, 52KB]
Workers' Comp/Home/Forms
Form 108 - CWP2 [pdf, 14KB]
Workers' Comp/Home/Forms
Form 11 [docx, 70KB]
Workers' Comp/Workers' Claims/Forms
FORM 110-I [docx, 48KB]
Workers' Comp/Workers' Claims/Forms
Form 111 [docx, 28KB]
Workers' Comp/Home/Forms
Form 113 [doc, 42KB]
Workers' Comp/Home/Forms
Form 114 [doc, 50KB]
Workers' Comp/Home/Forms
Form 115 [doc, 38KB]
Workers' Comp/Home/Forms
Form 120EX [doc, 96KB]
Workers' Comp/Home/Forms
Form 120EX [pdf, 15KB]
Workers' Comp/Home/Forms
Form 120EX [docx, 100KB]
Workers' Comp/Workers' Claims/Forms
Form AWW1 [docx, 31KB]
Workers' Comp/Home/Forms
Form AWWCON [docx, 31KB]
Workers' Comp/Home/Forms
Form AWWPOST [docx, 31KB]
Workers' Comp/Home/Forms
FORM SI-01 [doc, 57KB]
Workers' Comp/Home/Forms
FORM SI-02 [doc, 53KB]
Workers' Comp/Home/Forms
Form SI-02 Attachment August 2013 [doc, 85KB]
Workers' Comp/Home/Forms
Form SI-02R [doc, 57KB]
Workers' Comp/Workers' Claims/Forms
Form SI-03 Continuous Bond [pdf, 24KB]
Workers' Comp/Workers' Claims/Forms
Form SI-03 Attachment [doc, 40KB]
Workers' Comp/Home/Forms
Form SI-04 [doc, 39KB]
Workers' Comp/Home/Forms
Form SVC [docx, 24KB]
Workers' Comp/Home/Forms
Form SVE [docx, 25KB]
Workers' Comp/Home/Forms
Hearing Loss Stipulations 5-27-15 [docx, 61KB]
Workers' Comp/Home/Forms
IA1 First Report of Injury [pdf, 158KB]
Workers' Comp/Workers' Claims/Forms
IAIABC Electronic Trading Partner Profile [doc, 50KB]
Workers' Comp/Workers' Claims/Forms
IAIABC Electronic Trading Partner Profile 07-05 [pdf, 15KB]
Workers' Comp/Home/Forms
IAIABC Electronic Trading Partner Profile 07-05 (2) [pdf, 89KB]
Workers' Comp/Workers' Claims/Forms
IAIABC Electronic Transmission Profile Revised 11-8-10 [pdf, 25KB]
Workers' Comp/Home/Forms
Injury Stipulation 5-27-15 [docx, 81KB]
Workers' Comp/Home/Forms
Ky Drug-Free Workplace Application [pdf, 109KB]
Workers' Comp/Drug Free Workplace/Application; Document; Forms
Ky Drug-Free Workplace Application [pdf, 106KB]
Workers' Comp/Drug Free Workplace/Application; Document; Drug-Free Workplace; Forms
Letter of Credit [pdf, 53KB]
Workers' Comp/Home/Forms
Loss Report [pdf, 5KB]
Workers' Comp/Home/Forms
Managed Care - UR Form [doc, 38KB]
Workers' Comp/Home/Forms
Managed Care-UR Form [pdf, 7KB]
Workers' Comp/Home/Forms
Manual Change Form 2009 [doc, 48KB]
Workers' Comp/Workers' Claims/Forms
Manual Change Form 2009 [pdf, 120KB]
Workers' Comp/Workers' Claims/Forms
Medical Dispute [pdf, 69KB]
Workers' Comp/Home/Forms
Medical Dispute [docx, 29KB]
Workers' Comp/Home/Forms
MEDICAL REPORT IN SUPPORT OF APPLICATION FOR CONTINUATION OF MEDICAL BENEFITS (10-4-18 rev) [pdf, 254KB]
Workers' Comp/Workers' Claims/Document; Forms
Medical Report-Injury/Hearing Loss/Psychological Condition [pdf, 167KB]
Workers' Comp/Workers' Claims/Forms
Medical Waiver and Consent Form [pdf, 16KB]
Workers' Comp/Home/Forms
Microsoft Word - Draft 107 5-28-2015.doc [docx, 140KB]
Workers' Comp/Workers' Claims/Forms
Microsoft Word - Revised 101 form [docx, 124KB]
Workers' Comp/Workers' Claims/Forms
Motion to Reopen [pdf, 126KB]
Workers' Comp/Workers' Claims/Forms
Motion to Substitute Party and Continue Benefits [pdf, 126KB]
Workers' Comp/Workers' Claims/Forms
MTR-1 [docx, 96KB]
Workers' Comp/Workers' Claims/Forms
MTR-1 [doc, 46KB]
Workers' Comp/Workers' Claims/Forms
MTR-1 [pdf, 101KB]
Workers' Comp/Workers' Claims/Forms
MTR-2 [doc, 50KB]
Workers' Comp/Home/Forms
MTR-2 [pdf, 15KB]
Workers' Comp/Home/Forms
MTR-2 [doc, 48KB]
Workers' Comp/Workers' Claims/Forms
MTR-2 [pdf, 120KB]
Workers' Comp/Workers' Claims/Forms
Notice of Claim Denial or Acceptance [pdf, 67KB]
Workers' Comp/Home/Forms
Notice of Claim Denial or Acceptance [doc, 45KB]
Workers' Comp/Home/Forms
Notice of Claim Denial or Acceptance [pdf, 17KB]
Workers' Comp/Home/Forms
Notice of Designated Physician [pdf, 19KB]
Workers' Comp/Home/Forms
Occupational Disease Stipulation 5-27-15 [docx, 55KB]
Workers' Comp/Home/Forms
Open Records Request [pdf, 134KB]
Workers' Comp/Workers' Claims/Forms
Open Records Request [doc, 44KB]
Workers' Comp/Workers' Claims/Forms
Plaintiff's Chronological Medical History [pdf, 31KB]
Workers' Comp/Home/Forms
Plaintiff's Employment History [pdf, 33KB]
Workers' Comp/Home/Forms
Preferred Notary Form [pdf, 34KB]
Workers' Comp/Home/Forms
Previously Filed Form 4 or Form 5 Request [pdf, 96KB]
Workers' Comp/Compliance/Forms
Proof of Coverage [pdf, 141KB]
Workers' Comp/Home/Forms
Release of Records Form [pdf, 44KB]
Workers' Comp/Workers' Claims/Open Records; EDI; EDI Claims; EDI POC; Forms
Request for copies/inspection of Self-Insurance files. [pdf, 137KB]
Workers' Comp/Compliance/Records; Forms
Request for Expedited Determination of Medical Issue [pdf, 161KB]
Workers' Comp/Workers' Claims/Forms
Safety Violation Alleged by Defendant/Employer [pdf, 35KB]
Workers' Comp/Home/Forms
Safety Violation Alleged by Plaintiff/Employee [pdf, 34KB]
Workers' Comp/Home/Forms
Self Insurance Open Records Request Form [pdf, 10KB]
Workers' Comp/Workers' Claims/Forms
Self Insurance Package [pdf, 159KB]
Workers' Comp/Workers' Claims/Application; Forms
Self-Insurance Application [pdf, 35KB]
Workers' Comp/Home/Forms
Self-Insurance Application Attachment [pdf, 198KB]
Workers' Comp/Home/Forms
Self-Insurers' Guarantee Agreement [pdf, 16KB]
Workers' Comp/Home/Forms
Service Contract Agreement [pdf, 3KB]
Workers' Comp/Home/Forms
Service Contract Agreement [doc, 39KB]
Workers' Comp/Home/Forms
Social Security Release Form [pdf, 7KB]
Workers' Comp/Home/Forms
Subpoena [pdf, 8KB]
Workers' Comp/Home/Forms
Subpoena [doc, 45KB]
Workers' Comp/Home/Forms
Subpoena Duces Tecum [pdf, 8KB]
Workers' Comp/Home/Forms
Subpoena Duces Tecum [doc, 39KB]
Workers' Comp/Home/Forms
Surety Rider [pdf, 8KB]
Workers' Comp/Home/Forms
TRANSMISSION PROFILE -- RECEIVER'S SPECIFICATIONS [doc, 78KB]
Workers' Comp/Home/Forms
Workers Comp Posting Notice [doc, 1MB]
Workers' Comp/Home/Forms
Workers' Comp Statistical Report (Form 150) [xls, 64KB]
Workers' Comp/Compliance/Forms
Workers' Compensation Board Application Supplement-2022 [pdf, 107KB]
Workers' Comp/Workers' Claims/Forms
Workers' Compensation Board Application Supplement-November 2021 [pdf, 104KB]
Workers' Comp/Workers' Claims/Forms
Workers' Compensation-Hearing Loss Stipulation [pdf, 190KB]
Workers' Comp/Home/Forms
Workers' Compensation-Injury Stipulation [pdf, 290KB]
Workers' Comp/Home/Forms
Workers' Compensation-Occupational Disease Stipulation [pdf, 286KB]
Workers' Comp/Home/Forms