Free 104.PDF - Kentucky

FORM 104 ADOPTED January 1, 1997

KENTUCKY DEPARTMENT OF WORKERS CLAIMS PLAINTIFF'S EMPLOYMENT HISTORY Name Social Security Number

Name and Address of Employer
(Begin with most recent employer)

Type of Industry

Occupation

Period of Employment Begin date End date Month/Yr. Month/Yr

Exposure to substances causing occupational disease (specify substance)

1.

2.

3.

4.

5.

6.

7.

I hereby certify that the above information is true and correct to the best of my knowledge and belief. ____________________________________________ Plaintiff's Signature __________________________________________ Date