Form 102-Od - Application For Resolution Of Occupational Disease Claim (Page 3 of 4) in pdf

Form 102-Od - Application For Resolution Of Occupational Disease Claim Page 3

18. Has plaintiff returned to work? _____yes _____no; if yes, name and address of current employer and description of

job currently being performed: ____________________________________________________________________

_____________________________________________________________________________________________

Is plaintiff still working in environment where he/she is exposed to the hazards of the disease? _____yes _____no

Number of years of exposure to hazards of occupational disease _________________________________________

Has plaintiff been exposed to the disease while working for more than one employer? _____yes _____no

19. Weekly wage currently earned:_____________ Attach copy of any proof of current wages.

20. Are you alleging a violation of a safety rule/regulation pursuant to KRS 342.165? _____yes _____no

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____.

_________________________________________

Notary Public

My Commission expires:____________ County: _________________

Prepared and submitted by:

___________________________________

Signature/Representative for Plaintiff

___________________________________

Title

___________________________________

Street Address

___________________________________

City/State/Zip

___________________________________

Telephone Number

Form 102-Od - Application For Resolution Of Occupational Disease Claim Page 3