Free Form 102-CWP - Kentucky

Form 102-CWP Revised 6/05

KENTUCKY DEPARTMENT OF WORKERS' CLAIMS Application for Resolution of Coal Workers' Pneumoconiosis Claim Claim No. ___________________
vs. ........................................ Defendant/Employer ........................................ Street Address ........................................ City/State/Zip Code ........................................ Insurance Carrier ........................................ Street Address ........................................ City/State/Zip Code

........................................ Plaintiff . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Social Security Number . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Birth Date ........................................ Street Address ......... ............................... City/State/Zip Code ........................................ County ........................................ Phone

. . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . Other Defendant ........................................ Street Address ........................................ City/State/Zip Code Reason for Joinder: ............................. ..... ..... ........................................

Filed:

........................................ Other Defendant ........................................ Street Address ........................................ City/State/Zip Code Reason for Joinder: ........................................ ........................................

I. 1.

Nature of Occupational Disease
(day) (month) (year)

Plaintiff states that on the ................................ day of ..........................................., 20.........., he/she became affected by coal workers' pneumoconiosis arising out of and in the course of his/or her employment.

2. 3. 4.

State the date and means by which plaintiff gave notice of the injury to employer. ________________________________________________________________________ Place of last exposure:___________________________________________
(city) (county) (state)

Nature of the work in which the plaintiff was engaged at the time of exposure ________________________________________________________________________ How did exposure to the disease occur? (Describe in detail) ________________________________________________________________________ II. Personal Data

5.

6. 7. 8. 9.

Name and address of last school attended: ____________________________________ Highest grade completed in school: __________________________________________ GED awarded: _____ yes _____no Professional or vocational degrees, certificates, or licenses: ________________________ ________________________________________________________________________ Dependents: Name Social Security Number Relationship

10.

11.

Has plaintiff previously filed a claim for Kentucky coal workers' pneumoconiosis benefits (including retraining incentive benefits)? ___yes ___no If yes, give the date and defendant in previous claim: ___________________________ _______________________________________________________________________ III. Employment Data

12.

Weekly wage at date of last exposure: _____________________________________ Attached copy of any proof wages, such as paycheck stub, W-2, etc. Is plaintiff currently employed? ___ yes ___no Name and address of current employer : _______________________________________ ________________________________________________________________________ Is plaintiff still working in an environment where he/she is exposed to the hazards of the disease ? ____ yes ____ no Number of years of exposure to hazards of occupational disease________

13.

14.

15.

16.

Has plaintiff been exposed to the disease while working for more than one employer? ____ yes ____ no Weekly wage currently earned: _________ Attach copy of any proof of current wages. IV. Medical Data

17.

18.

List name and address of "B" reader whose report is attached to this Form. File original x-ray read by this "B" reader with this form. Name of "B" Reader Address

19.

Are you alleging a pulmonary impairment as the result of coal dust exposure? _____ yes ______ no If yes, attach results of pulmonary function studies and tracings. Are you alleging a violation of a safety rule/regulation pursuant to KRS 342.165? no_____ yes_____

20.

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 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 are true. This the day of _________ 20____.

______________________________ Plaintiff's Signature

Subscribed and sworn to before me this

day of

20

.

My Commission expires: __________

______________________________ Notary Public County: _______________________

Prepared and submitted by:

_______________________________ Signature of Attorney for Plaintiff _______________________________ Name of Attorney (Print or Type)

_______________________________ Street Address _______________________________ City/State/Zip Code __________________________ Telephone Number

Instructions for Completion of Forms 101, 102, 102-CWP and 103
Form 101 - Application for Resolution of Injury Claim 1. All sections of this form must be completed, and must be accompanied by the following: 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. All information must be typewritten. File the original of this form and sufficient copies for all named defendants with the Department of Workers' Claims, Prevention Park, 657 Chamberlin Ave., Frankfort, Kentucky, 40601. If you have no telephone number, please list a number at which you may be contacted. If you have questions, call 1-800-554-8601. Form 102 & Form 102-CWP - Application for Resolution of Occupational Disease Claim, and Form 103 - Application for Resolution of Hearing Loss Claim 1. All sections of this form must be completed, and must be accompanied by the following: 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 of "B" reader supporting the disease. (Applies to 102-CWP only) e. Original x-ray read by "B" reader (Applies to 102-CWP only) f. Pulmonary function studies and tracings if a pulmonary impairment is alleged g. Proof of Wages, including W-2's, paycheck stubs, etc. h. Social Security earnings record release form This form may be filed in combination with an Application for Resolution of Injury Claim (Form 101) if both benefits are sought. Information provided should be current through the date application is signed by plaintiff. All information must be typewritten. File the original of this form and sufficient copies for all named defendants with the Department of Workers' Claims, Prevention Park, 657 Chamberlin Ave., Frankfort, Kentucky, 40601. If you have questions, call 1-800-554-8601.

2. 3.

4. 5.

2.

3. 4.

5.

Note: Please list the correct name and address of the employer and insurance carrier to avoid delay in processing the claim.

Revised July, 2002