Form 102-Od - Application For Resolution Of Occupational Disease Claim printable pdf download

Form 102-Od - Application For Resolution Of Occupational Disease Claim

KENTUCKY

Form 102-OD

DEPARTMENT OF WORKERS’ CLAIMS

Revised 6/05

Application for Resolution of Occupational Disease Claim

Claim No. _____________________

____________________________

_____________________________

vs.

Plaintiff

Defedant/Employer

_________________________________

___________________________________

Social Security Number

Street Address

_________________________________

___________________________________

Birth Date

City/State/Zip Code

_________________________________

___________________________________

Street Address

Insurance Carrier

_________________________________

___________________________________

City/State/Zip Code

Street Address

_________________________________

___________________________________

County

City/State/Zip Code

_________________________________

___________________________________

Phone Number

Other Defendant

___________________________________

Filed:

Street Address

___________________________________

City/State/Zip Code

Reason for Joinder:

___________________________________

Other Defendant

___________________________________

Street Address

___________________________________

City/State/Zip Code

Reason for Joinder:

___________________________________

__________________________________

I. Nature of Occupational Disease

Plaintiff states that on the _______ day of ________ 20____, he/she became affected by reason of a disease arising

out of and in the course of his/or her employment.

Identify the occupational disease(s) claimed:__________________________________________________________

Form 102-Od - Application For Resolution Of Occupational Disease Claim

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