Free MTR-3.DOC - Kentucky

MTR-3 Motion to Reopen by Defendant May 29, 1997 Edition

COMMONWEALTH OF KENTUCKY DEPARTMENT OF WORKERS CLAIMS CLAIM NO. __________________ BEFORE _____________________

_____________________________ (EMPLOYEE)

PLAINTIFF

VS.

MOTION TO REOPEN BY DEFENDANT

_____________________________ (EMPLOYER) _____________________________ (INSURANCE CARRIER) _____________________________ (OTHER DEFENDANTS, IF APPLICABLE) _____________________________ (SPECIAL FUND, IF APPLICABLE)

DEFENDANT(S)

***************

The undersigned defendant moves to reopen this claim based on the following grounds (check all that apply): ___ ___ ___ ___ ___ ___ ___ Change of disability shown by objective medical evidence Fraud Mistake Newly discovered evidence Medical fee dispute Conforming the award to employee's work status for injuries after 12-12-96. Reducing a permanent total disability award when employee returns to work.

Explanation: ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ The undersigned further states that the following information is correct (check appropriate response): 1. __ No previous motion to reopen has been filed. __ Previous motion to reopen filed Month On medical fee disputes: 2. __ Utilization review was done on (DATE) __ Utilization review is not required because . A copy of the decision is attached. Day Year

This motion is supported by the following attached documents: 1. Affidavit(s) of ______________________________________________ (WITNESS NAMES)

2. Medical report of ____________________________________________ (DOCTOR'S NAME)

3. A current medical release Form 106 signed and witnessed. 4. A copy of the Opinion and Award, Settlement, Agreed Order, or Agreed Resolution sought to be reopened.

The undersigned, being duly sworn, states the foregoing statements in this motion and in Form 106 are true and accurate to the best of my knowledge and belief. This the _______ day of _________________ 20____.

____________________________________ (DEFENDANT'S SIGNATURE)

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

____________________________________ NOTARY PUBLIC

My Commission expires: ______________________ County: ___________________________

Respectfully submitted,

____________________________________ (DEFENDANT'S SIGNATURE) ____________________________________ (DEFENDANT'S STREET ADDRESS) ____________________________________ (DEFENDANT'S 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 fact material thereto commits a fraudulent insurance act, which is a crime.

CERTIFICATE OF SERVICE I certify that the original was mailed to 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 Employee if applicable: ___________________________________________ (Attorney Name or Law Firm) ___________________________________________ (Attorney Address or Law Firm Street Address) ___________________________________________ (Attorney Address, City/State/Zip)

Employee:

___________________________________________ (Employee's Name) ___________________________________________ (Employee's Street Address) ___________________________________________ (Employee's City/State/Zip)

Other Parties, if applicable:

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

Special Fund, if applicable:

___________________________________________ (Special Fund) __________________________________________ (Special Fund Street Address) __________________________________________ (Special Fund City/State/Zip)

This _______ day of ________________, 20____.

__________________________________________ (Defendant's Signature)