| 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 |
| Form EL1 & EL2.doc |
Form EL1 & EL2.pdf |
Employee Leasing Company Registration 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 |