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When workers in Kentucky experience an injury on the job that leads to medical treatment, time off work, or even more serious consequences, navigating the aftermath can feel overwhelming. Fortunately, the Kentucky Department of Workers' Claims has streamlined the process through the Kentucky 101 form, officially known as the Application for Resolution of a Claim – Injury. This form is comprehensive, designed to capture all pertinent details of the claim, from basic information like the claimant's and employer's details, including Social Security or Green Card number, occupation, and contact information, to specific details about the injury itself such as the date, location, cause, and nature of the injury. It even goes further to inquire about any subsequent medical treatment, details of the physician providing a report, and if an interpreter is necessary for a formal hearing. Additionally, the form asks about the worker's employment status at the time of injury, any previous workers’ compensation benefits received, and current employment status. It also invites documentation related to concurrent employment at the time of injury, eligibility for dependents in the case of the claimant's death, and the allegation of any safety rule violations. The sincerity of the information provided is underscored through required attestations against fraudulent claims. Instructions accompanying the form emphasize the necessity of completing all sections accurately and submitting additional documentation such as employment history, medical history, and proof of wages, aiming to ensure the claim's processing is as smooth and swift as possible.

Kentucky 101 Sample

Application for Resolution of a Claim – Injury

October 2016 Edition

KENTUCKY DEPARTMENT OF WORKERS’ CLAIMS

Application for Resolution of a Claim - Injury

Claim No.

vs.

Plaintiff

Social Security Number/ Green Card

Birth DateGender

Plaintiff Mailing Address

City/State/Postal Code

☐Outside United States

Country

Plaintiff’s Phone Number

Occupation

Filed:

Defendant/Employer (Business Name)

Defendant/ Employer Mailing Address

City/State/Postal Code

Insurance Carrier

Insurance Carrier Mailing Address

City/State/Postal Code

Additional Defendants

Additional Defendant

Mailing Address

City/State/Postal Code

Reason for Joinder:

Additional Defendant

Mailing Address

City/State/Postal Code

Reason for Joinder:

I. Nature of Injury

1.Date and location of accident/injury:

Date of Injury

Location of Injury (City/State/Postal Code)

☐Plaintiff states that he/she was injured within the scope and course of employment with defendant employer on the above date at the above location.

2.Describe how the accident/injury occurred:

Cause of Injury:

3.Body part injured:

4.When and by what means did the plaintiff give notice of injury to the employer?

5.Describe medical treatment, if any:

6.Name and address (city/state/postal code) of physician whose report will be provided:

7.Will an interpreter be needed for the formal hearing? (Yes / No) If yes, in which language?

8.Dependents

Injured worker is deceased? (Yes / No)

If deceased, dependent information is required for a deceased worker. If work injury resulted in the death of claimant, attach/provide/upload Form F in addition to the application for Resolution of Claim.

9.Have you previously filed for or received workers’ compensation benefits in Kentucky? (Yes / No) If yes, please provide the following information:

Claim Number

Date of Injury

Nature of Injury/Disease

Awards/Benefits

 

 

 

 

 

 

 

 

 

 

 

 

If not a Kentucky claim, please provide the state in which you were awarded benefits:

10.Was there concurrent employment at the time of injury? (Yes / No)

11.Name and address of concurrent employer:

Concurrent Employer Name

Concurrent Employer City

Concurrent Employer State

Postal Code

12.Has the plaintiff worked since the injury? (Yes / No)

13.Name and address of current employer and description of job currently being performed: Current Employer Name

Current Employer City

Current Employer State

 

Postal Code

Description of Job Performed:

14.Are you alleging a violation of a safety rule/regulation pursuant to KRS 342.165? (Yes / No) If yes, submit form SVC within 15 days after filing the Application for Resolution of Claim.

Attestations:

I understand that any person who knowingly and with intent to defraud any insurance company or other person files a

☐statement or claim containing any materially false information or conceals, for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act, which is a crime.

☐Plaintiff herein being duly sworn, states that the statements in this application and in Form 104, 105, and 106 to be separately filed, are true.

By entering your name below, you are confirming the accuracy of this form to the best of your knowledge.

This form prepared and submitted by

 

Relationship to injured worker

 

 

 

Submitter Phone Number

 

Submitter Email Address

 

 

 

Plaintiff Signature

 

 

Instructions for Completion of – Application for Resolution of a Claim – Injury

1.All sections of this form must be completed, and the following shall be filed within 15 days:

a.Form 104 (Plaintiff’s Employment History)

b.Form 105 (Plaintiff’s Chronological Medical History)

c.Form 106 (Medical Waiver and Consent)

d.Medical report describing and supporting the injury which is the basis of the claim.

e.Proof of Wages, including W-2’s, paycheck stubs, etc.

2.All information must be typewritten

3.File the original of this form and sufficient copies for all named defendants with the Department of Workers’ Claims, Prevention Park, 657 Chamberlin Avenue, Frankfort, Kentucky, 40601.

4.If you have no telephone number, please list a number at which you may be contacted.

5.If you have questions, call 1-800-554-8601.

Note: Special attention should be given to stating the correct name and address of the employer and insurance carrier. Otherwise, claim processing may be delayed.

Free Kentucky 101 File

Form Features

Fact Name Description
Form Purpose The Kentucky 101 form is used to apply for the resolution of a workers' compensation claim due to an injury.
Edition The form's edition is October 2016.
Governing Body The form is governed by the Kentucky Department of Workers' Claims.
Key Requirements All sections must be completed, and additional forms (Form 104, 105, 106) and medical reports must be filed within 15 days.
Typewritten Information All information on the form must be typewritten.
Submission Address Forms are to be filed with the Department of Workers' Claims located at Prevention Park, 657 Chamberlin Avenue, Frankfort, Kentucky, 40601.
Insurance Fraud Warning The form includes a warning about the legal consequences of committing insurance fraud.
Contact Information Requirement If the plaintiff does not have a telephone number, an alternative contact number is required.
Assistance Available For questions, there is a helpline available at 1-800-554-8601.

Detailed Steps for Using Kentucky 101

Filling out the Kentucky 101 form, also named "Application for Resolution of a Claim – Injury", is a necessary step for individuals looking to resolve a workplace injury claim in the state of Kentucky. This form collects detailed information about the plaintiff, the defendant or employer, the nature of the injury, and any treatment received. It's important to be thorough and accurate when completing this form to ensure your claim is processed efficiently and accurately. Below are the instructions for filling out the form step by step.

  1. Start by entering the Claim No. if known, otherwise leave it blank.
  2. Fill out the plaintiff’s information including Social Security Number/Green Card number, Birth Date, and Gender.
  3. Provide the Plaintiff Mailing Address including city, state, and postal code. If outside the United States, check the appropriate box and include the country.
  4. Enter the Plaintiff’s Phone Number and Occupation.
  5. List the Defendant/Employer information including the business name and mailing address.
  6. For the Insurance Carrier, include both the name and mailing address.
  7. If there are Additional Defendants, list their information and the Reason for Joinder.
  8. In the section titled "Nature of Injury", provide the Date and Location of Accident/Injury, a description of how the injury occurred, what body part was injured, and when the employer was notified.
  9. Describe any medical treatment received and provide the name and address of the physician whose report will be submitted.
  10. Indicate whether an interpreter will be needed for the formal hearing and specify the language if applicable.
  11. If the injured worker is deceased, answer "Yes" and provide dependent information separately.
  12. Answer whether you have previously filed for or received workers’ compensation benefits in Kentucky or another state. If "Yes", provide additional information as requested.
  13. Indicate if there was concurrent employment at the time of the injury and provide the concurrent employer's name and address.
  14. State whether the plaintiff has worked since the injury, and if so, list the current employer's name, address, and a description of the job being performed.
  15. If alleging a violation of a safety rule/regulation pursuant to KRS 342.165, answer "Yes" and remember to submit form SVC within 15 days after filing this application.
  16. Read the attestations carefully. If you agree, enter the plaintiff's name to confirm the accuracy of the information provided.
  17. Complete the section at the end by filling in your relationship to the injured worker, your phone number, and email address. Ensure the plaintiff signs the form.
  18. Review all sections of the form to ensure accuracy and completeness before submission.
  19. Submit the form along with required documents such as Form 104, Form 105, Form 106, medical reports, and proof of wages to the specified address. Remember to type all information and include sufficient copies for all named defendants.

After submitting the form and necessary documentation, your claim will be processed by the Department of Workers’ Claims. It's essential to provide accurate and complete information to avoid any delays in processing your claim. If you have any questions during this process, do not hesitate to call the provided contact number for assistance.

Obtain Clarifications on Kentucky 101

  1. What is the Kentucky 101 form?
    The Kentucky 101 form, also known as the Application for Resolution of a Claim - Injury, is a document used in the state of Kentucky for workers who have been injured on the job to apply for workers' compensation benefits. This form initiates the process for a claim resolution between an injured worker (plaintiff) and their employer (defendant), along with any additional defendants such as insurance carriers.

  2. How does one complete the Kentucky 101 form?
    To correctly fill out the Kentucky 101 form, all sections must be completed with typewritten information. This includes personal information, details about the injury and how it occurred, medical treatment received, and employment information. Additionally, within 15 days of filing, the following documents must also be filed: Form 104 (Plaintiff’s Employment History), Form 105 (Plaintiff’s Chronological Medical History), Form 106 (Medical Waiver and Consent), a medical report supporting the injury claim, and proof of wages.

  3. Where does one file the Kentucky 101 form?
    The original form and sufficient copies for all named defendants must be filed with the Department of Workers’ Claims located at Prevention Park, 657 Chamberlin Avenue, Frankfort, Kentucky, 40601. It's important to ensure that the correct name and address of the employer and insurance carrier are provided to avoid processing delays.

  4. What happens if information is falsely provided on the form?
    Providing false information or concealing facts intentionally on the Kentucky 101 form is considered a fraudulent insurance act, which is a crime. Such actions include submitting claims with materially false information or misleading by hiding information pertinent to the claim. This can lead to legal repercussions against the person committing the fraud.

  5. Is it necessary to have a lawyer to file the Kentucky 101 form?
    While it is not mandatory to have a lawyer to file the Kentucky 101 form, seeking legal advice can be beneficial. A lawyer who specializes in workers' compensation can provide guidance through the process, help in preparing the necessary documentation, and represent the injured worker in proceedings if needed.

  6. What if an interpreter is needed for the formal hearing?
    If you need an interpreter for the formal hearing, indicate 'Yes' on the form and specify the language required. The Department of Workers’ Claims will arrange for an interpreter to assist during the hearing process to ensure that all parties can fully participate and understand the proceedings.

  7. Can I file a claim if the worker is deceased?
    Yes, if the work injury resulted in the death of the claimant, dependent information is required on the form. Additionally, Form F must be attached/provided/uploaded in addition to the Application for Resolution of Claim. This allows dependents to seek compensation benefits on behalf of the deceased worker.

  8. What evidence is required to support the injury claim?
    Supporting evidence for the injury claim includes a medical report detailing the injury and its relation to the employment, proof of wages such as W-2 forms and paycheck stubs, and completed forms 104, 105, and 106 that provide employment and medical history. Submitting comprehensive and accurate evidence is crucial for the successful processing of the claim.

  9. What should I do if I have no telephone number?
    If you do not have a telephone number, you should provide an alternative number at which you can be contacted. This could be the number of a family member, friend, or legal representative. It's important that the Department of Workers’ Claims has a way to reach you for updates or requests for additional information regarding your claim.

  10. Who can I contact if I have questions about filling out the form?
    If you have any questions regarding completing the Kentucky 101 form, you can call the Department of Workers’ Claims at 1-800-554-8601 for assistance. They can provide guidance on how to properly fill out the form and answer any specific questions you might have about the claims process.

Common mistakes

Filling out the Kentucky 101 form, officially known as the Application for Resolution of a Claim – Injury, is a critical step for workers seeking compensation for injuries sustained on the job. However, applicants often make errors that can complicate or delay the processing of their claim. Understanding these common mistakes can help ensure smoother processing.

  1. Not providing complete information for all sections: One of the main errors is the failure to fill out all required sections of the form. Every part of the form serves a purpose, from detailing the nature of the injury to providing information about dependents. Leaving sections blank or incomplete can lead to delays, as the Department of Workers’ Claims may need to request additional information before proceeding.

  2. Incorrect employer and insurance carrier information: Special attention should be given to accurately stating the name and address of the defendant/employer and the insurance carrier. Errors in this information not only delay the processing of the claim but can also affect the outcome, as it may hinder the ability of the Department to provide notices or gather necessary information.

  3. Failure to include concurrent employment: If there was concurrent employment at the time of the injury, this must be disclosed, along with the name and address of the concurrent employer. Overlooking this detail can lead to an incomplete assessment of the claimant's employment situation and potential benefits.

  4. Omitting medical and wage documents: The requirement to file additional forms and documents, such as the plaintiff’s employment history (Form 104), medical history (Form 105), and proof of wages, is often overlooked. These documents are crucial for supporting the claim and must accompany the application within the specified time frame.

  5. Not attesting to the truthfulness and accuracy of the information: At the end of the application, claimants must attest to the accuracy and truthfulness of the information provided. Failing to do so—or doing so inaccurately—can be considered fraudulent and may result in the denial of the claim or legal action against the claimadnt.

In summary, when filling out the Kentucky 101 form, it’s essential to:

  • Complete all required sections with accurate and thorough information.
  • Ensure that the employer and insurance carrier details are correctly stated.
  • Include information on any concurrent employment at the time of injury.
  • Attach all required additional forms and documents to support the injury claim.
  • Accurately attest to the information provided to avoid potential legal penalties.

By avoiding these common mistakes, claimants can help ensure that their application for claim resolution is processed efficiently and without unnecessary delay.

Documents used along the form

When filing an Application for Resolution of a Claim – Injury (Kentucky 101 form) for an injury sustained in the workplace within Kentucky, several additional forms and documents might be required to support your claim effectively. These additional materials provide a comprehensive overview of your employment history, medical treatments, and other pertinent information that can influence the resolution of your claim. Here's an overview of up to 10 forms and documents you may need to gather or complete in conjunction with the Kentucky 101 form.

  • Form 104 (Plaintiff’s Employment History) - This form documents the injured worker's employment history, including previous positions and employers. It helps establish the claimant's work experience and potential exposure to risk factors that may have contributed to the injury.
  • Form 105 (Plaintiff’s Chronological Medical History) - Essential for detailing the medical history of the claimant, this form records any previous injuries, conditions, or treatments that could affect the current injury claim resolution.
  • Form 106 (Medical Waiver and Consent) - By signing this document, the claimant authorizes the release of their medical records to involved parties, ensuring that all relevant medical information is available for review.
  • Medical Report - A doctor's report describing and supporting the injury claimed is critical. It should detail the extent of the injuries, the expected recovery path, and any ongoing treatment needs.
  • Proof of Wages - Documents such as W-2 forms and paycheck stubs are required to establish the claimant's earnings, which are necessary for calculating potential compensation.
  • Form F - If the work injury has resulted in the death of the claimant, this form is necessary to collect dependent information and to process the claim accordingly.
  • Form SVC - If the claimant alleges a violation of a safety rule/regulation, this form needs to be submitted to outline the specifics of the violation and how it contributed to the injury.
  • Interpreters Request Form - Should the injured worker or any witnesses require an interpreter during hearings, this form specifies the language needed and ensures appropriate arrangements are made.
  • Change of Address Form - It's crucial to keep contact information up to date. This form should be submitted whenever there's a change in the claimant's mailing address, ensuring all correspondences reach them promptly.
  • Application for Reopening a Claim - If the condition of the injured worker changes or if there was an error in the resolution of the original claim, this application allows for the case to be reopened for further review.

Gathering and accurately completing these forms and documents in conjunction with the Kentucky 101 form is crucial for the timely and proper resolution of your work injury claim. They provide the necessary context and evidence to understand the circumstances of the injury, the impact on your health, and the financial implications. Ensuring that all information is complete and accurate can dramatically affect the outcome of your claim.

Similar forms

The Kentucky 101 form, an Application for Resolution of a Claim - Injury, shares similarities with Form I-130, Petition for Alien Relative used in immigration processes. Both forms collect basic personal information, such as social security numbers or green card information, and addresses. They are designed for applicants to provide detailed data regarding a specific situation - in the case of the Kentucky 101 form, an injury at work, and for Form I-130, the relationship with a relative seeking to immigrate. Each form requires the petitioner to attest to the truthfulness of the information provided, under penalty of law for false statements.

Similar to the Form SSA-821-BK (Work Activity Report) used by the Social Security Administration, the Kentucky 101 form demands detailed work-related information from the claimant. Both forms inquire about the claimant's employment status, name and address of the employer, and specific details regarding the job performed or work activity. Such information is crucial in assessing the claimant's eligibility for benefits - for workers' compensation claims in the Kentucky 101 form and for determining the correct Social Security disability benefits in the SSA-821-BK form.

The Kentucky 101 form is akin to the OSHA Form 301 (Injury and Illness Incident Report), as both are focused on documenting the specifics of workplace injuries or illnesses. Each form requires descriptions of how the injury occurred, the nature of the injury, and subsequent medical treatment. While the Kentucky 101 form is used for workers' compensation claims, the OSHA 301 form helps employers record and report occupational injuries and illnesses as mandated by the Occupational Safety and Health Administration. The detailed recording is vital for both regulatory compliance and the resolution of workers' compensation claims.

Another document related to the Kentucky 101 form is the FMLA (Family and Medical Leave Act) application forms used for securing leave due to a serious health condition that makes the employee unable to perform job functions. Both sets of documents necessitate medical information related to the condition or injury. However, while the Kentucky 101 form is for claiming workers' compensation benefits due to a workplace injury, FMLA application forms are for obtaining protected leave, showcasing the comparison in their use of medical data to serve different legal purposes.

Lastly, the Kentucky 101 form resembles the VA Form 21-526EZ, Application for Disability Compensation and Related Compensation Benefits. Both forms are designed for individuals seeking benefits due to injuries - in the case of the Kentucky 101 form, injuries acquired at work, and for the VA Form 21-526EZ, injuries or conditions related to military service. Applicants must provide detailed information about their injury or condition, treatment received, and impact on their employment capabilities. Through these parallels, each form plays a crucial role in the respective benefit claim process of workers' compensation and veterans' disability compensation.

Dos and Don'ts

When it comes to filling out the Kentucky 101 form, also known as the Application for Resolution of a Claim – Injury, accuracy and completeness are your best friends. Here are five do's and five don'ts to help guide you through the process smoothly:

Do:
  • Ensure every section of the form is completed. Missing information can delay the resolution of your claim.
  • Type all information. This enhances readability and prevents misunderstandings.
  • Include all required additional forms and documents within 15 days, such as Form 104 (Plaintiff’s Employment History), Form 105 (Plaintiff’s Chronological Medical History), Form 106 (Medical Waiver and Consent), a medical report, and proof of wages.
  • Double-check the accuracy of the employer and insurance carrier’s name and address. Incorrect information can cause delays in your claim processing.
  • Sign the attestation, confirming that all the information provided is true and accurate to the best of your knowledge.

Don't:
  • Leave any sections blank. If a section does not apply, indicate with “N/A” or “None,” as appropriate.
  • Forget to file sufficient copies of the form for all named defendants. Each defendant needs a copy to respond to your claim.
  • Miss the 15-day deadline for submitting the required additional forms and documents. Late submissions can hinder the progress of your claim.
  • Submit handwritten forms. Although it might seem quicker, this can cause issues with legibility and potentially slow down the claim process.
  • Ignore the need for an interpreter if one is needed for the formal hearing. If you or any witnesses require an interpreter, be sure to indicate this on the form along with the required language.

By following these guidelines, you can help ensure that your claim is processed as efficiently and accurately as possible. Remember, the goal is to provide a clear and comprehensive account of your claim to facilitate a prompt resolution.

Misconceptions

Many people find the process of navigating workers' compensation claims daunting, particularly when it comes to filling out required forms like the Kentucky 101 form, officially known as the Application for Resolution of a Claim – Injury. Misunderstandings about these forms can lead to unnecessary stress and errors in filing. Below are six common misconceptions about the Kentucky 101 form, clarified to help individuals better understand the process and requirements.

  • Only physical injuries are covered: A misconception exists that the Kentucky 101 form is exclusively for physical injuries. While the form does focus on injuries sustained in the workplace, it is crucial to understand that related ailments, like stress-induced conditions due to the injury, may also be considered under the scope of a claim.
  • Personal attorney must file the form: While having an attorney can be beneficial, especially in complex cases, it's not a requirement for filing the Kentucky 101 form. Claimants can file on their own by carefully following the instructions provided with the form. However, consultation with a legal advisor may help in better understanding the rights and ensuring all necessary documentation is accurately completed.
  • The form is only for current employees: Another common misunderstanding is that only current employees can file a claim using the Kentucky 101 form. In reality, if an injury occurred during the course of employment with the named employer, even former employees have the right to file a claim.
  • All information must be filled in by the claimant: While the claimant needs to provide accurate and comprehensive information, some sections of the form, particularly those requiring specific details about medical treatment or legal representations, might be completed with the assistance of medical professionals or legal advisors.
  • Once submitted, no additional information can be added: Some believe that after submitting the Kentucky 101 form, they cannot add more information or documentation to support their claim. This is not the case; additional relevant information can be submitted to the Department of Workers’ Claims as it becomes available or as requested.
  • Interpreters are not allowed: The form explicitly inquires if an interpreter will be needed, indicating support for claimants who might not be comfortable with English. This inclusion ensures that all workers, regardless of language proficiency, have access to the claims process.

Understanding these points can dispel myths and reduce the intimidation factor associated with filing a workers' compensation claim in Kentucky. It's crucial for individuals to know they have resources and support throughout this process, aiming to protect their rights and well-being after a workplace injury.

Key takeaways

Understanding the Kentucky 101 form, officially known as the Application for Resolution of a Claim - Injury, is essential for workers and employers navigating the complexities of workplace injuries and claims. Here are key takeaways to guide you through the process:

  • Fully Complete the Form: Every section of the Kentucky 101 form must be thoroughly completed to avoid any delays in processing the claim.
  • Accompanying Documentation: Alongside the application, specific documents including the plaintiff’s employment history (Form 104), chronological medical history (Form 105), medical waiver and consent (Form 106), a medical report detailing the injury, and proof of wages must be submitted within 15 days.
  • Typewritten Information: To ensure clarity and legibility, all information provided on the application should be typewritten.
  • Submission Details: The original form, along with sufficient copies for all named defendants, must be filed with the Department of Workers’ Claims at their designated address in Frankfort, Kentucky.
  • Contact Information is Crucial: Applicants without a phone number should provide an alternative contact number to facilitate communication regarding the claim.
  • Accurate Employer and Insurance Carrier Details: Correctly stating the name and address of the employer and their insurance carrier is critical for the timely and efficient processing of the claim.
  • Attestation of Accuracy: By signing the form, the plaintiff attests to the truthfulness and accuracy of all information provided, acknowledging the legal implications of submitting false information.
  • Notification of Injury to Employer: The form requires detailed information about how and when the employer was notified of the injury, underscoring the importance of timely communication.
  • Requirement for Interpreters: If an interpreter is needed for the formal hearing, the application asks for this to be specified, including the language required.
  • Safety Rule Violation Allegation: If alleging a violation of a safety rule or regulation, a specific form (SVC) must be submitted within 15 days after filing the Application for Resolution of Claim.

This comprehensive approach ensures that all necessary details are accurately conveyed to the Department of Workers' Claims, aiding in the swift resolution of workplace injury claims in Kentucky.

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