Free Form MTR-2 - Kentucky

MTR-2 Motion to Reopen KRS 342.732 Benefits July 2002 Edition

COMMONWEALTH OF KENTUCKY DEPARTMENT OF WORKERS' CLAIMS CLAIM NO. ________________________ BEFORE _________________________

_____________________________ (EMPLOYEE)

PLAINTIFF

VS.

MOTION TO REOPEN KRS 342.732 BENEFITS

_____________________________ (EMPLOYER) _____________________________ (INSURANCE CARRIER) _____________________________ (OTHER DEFENDANTS)

DEFENDANT(S)

*************** The undersigned moves to reopen this coal workers pneumoconiosis claim. The order or award being reopened was : ___ ___ ___ An Order or Award for retraining incentive benefits. An Order or Award for other benefits under KRS 342.732. Dismissed due to a finding of no coal workers pneumoconiosis on x-ray or failure to meet medical eligibility standards.

This Order or Award was issued ___________/________/________.

The undersigned states that the grounds for reopening are stated below: ___ Progression of occupational disease resulting from coal workers pneumoconiosis . Development or progression of respiratory impairment due to occupational pneumoconiosis. Review of university x-ray in compliance with reconsideration procedures of KRS 342.732, effective 7-15-02. Last exposure prior to 12-12-96. Review of dismissal or award under KRS 342.732 as effective 715-02. Last exposure between 12-12-96 and 7-14-02. Medical fee dispute. Medical bills in question are attached.

___

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___

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___ Other: __________________________________________________ __________________________________________________ __________________________________________________.

The undersigned further states that the following information is correct: 1. The employee's last date of exposure to coal dust was ____________________. 2. The employee was awarded ____________ and received __________________ under the prior award or settlement for coal workers pneumoconiosis. 3. The employee /plaintiff states that the employee/plaintiff has _________ or has not __________ had two additional years of exposure to coal dust in the Commonwealth of Kentucky. This additional exposure was with ____________________________ at _______________________. 4. __ No previous motion to reopen has been filed. __ Previous motion to reopen was filed _______________/__________/_______. 5. On medical fee disputes: __ Utilization review was done on attached. __ Utilization review is not required because . A copy of the decision is

_____________________________________________.

The motion to reopen is supported by the following attached documents: (INCLUDE IF NEEDED) 1. 2. Affidavit(s) of _______________________________________________. Medical report of _____________________________________ showing progression of the disease by x-ray and/or pulmonary function studies (FVC, FEV1) showing development or progression of pulmonary impairment attributable to coal workers' pneumoconiosis. A current medical release (Form 106) which has been signed and witnessed. A copy of the Opinion and Award, Settlement, Agreed Order or Order of Dismissal sought to be reopened. Updated work history (Form 104) and medical history (Form 105).

3. 4.

5.

The undersigned, being duly sworn, states the foregoing statements in this motion and Forms 104, 105, & 106 are true and accurate to the best of my knowledge and belief.

__________________________________________ (MOVANTS SIGNATURE)

Subscribed and sworn to before me this _______ day of _________________ 20____.

__________________________________________ NOTARY PUBLIC

My Commission expires: ____________________________ County:______________________ Respectfully submitted,

__________________________________________ (MOVANTS SIGNATURE) __________________________________________ (MOVANTS STREET ADDRESS) __________________________________________ (MOVANTS CITY/STATE/ZIP CODE)

Notice:

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 material fact commits a fraudulent insurance act, which is a crime.

CERTIFICATE OF SERVICE I certify that the original was mailed to the Commissioner at the Department of Workers' Claims, Prevention Park, 657 Chamberlin Avenue, Frankfort, Kentucky 40601 and copies of this motion and attachments were mailed to the names and addresses of the parties given below:

Attorney for Employer or Insurance Carrier if applicable:

______________________________________________ (Attorney Name or Law Firm) ______________________________________________ (Attorney Address or Law Firm Street Address) ______________________________________________ (Attorney Address, City/State/Zip)

Employer or Insurance Carrier:

______________________________________________ (Company Name or Employer Name) ______________________________________________ (Company or Employer Street Address) ______________________________________________ (Company or Employer City/State/Zip)

Other Parties, if applicable:

______________________________________________ (Name of Party) ______________________________________________ (Party Street Address) ______________________________________________ (Party City/State/Zip)

This _______ day of ________________, 20____.

______________________________________________ (Movants Signature)