Workers' Compensation Notice - Kentucky Labor Cabinet

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COMMONWEALTH OF KENTUCKY
WORKERS’ COMPENSATION NOTICE
Employees of this business are covered by the Kentucky Workers’ Compensation Act (KRS
Chapter 342). Conspicuous posting of this Notice is required by law.
Employer Name: _______________________________________________________________________
Address: ______________________________________________________________________________
Workers Compensation Carrier
(or third party administrator): ___________________________________________________________
Policy #:________________________, effective _____________ to ______________________________
Address: ______________________________________________________________________________
Telephone: __________________, Contact Person ___________________________________________
EMPLOYEES: IF INJURED – NOTIFY your supervisor IMMEDIATELY; when possible
Notice should be in writing. FAILURE to notify your supervisor could result in denial of
benefits. OBTAIN MEDICAL CARE. Your employer must pay for ALL NECESSARY
MEDICAL CARE to treat a workplace injury. The employee may select the physician or
medical facility to render care. If the employer is enrolled in an approved Managed Care
Plan employee selection of physicians is LIMITED to the Approved Provider Network,
except in certain emergencies. FOR INJURIES REQUIRING CONTINUING CARE the
EMPLOYEE MUST DESIGNATE A TREATING PHYSICIAN, a form to do so will be
furnished by your employer or its insurance carrier.
This employer IS
IS NOT
participating in a Managed Care Plan for medical care. The
name of the Managed Care Plan is ________________________, its representative is
______________________________, phone number _________________________________.
DISABILITY BENEFITS to replace wages lost due to a workplace injury are payable
under the Workers Compensation Act after seven (7) day of disability. A CLAIM MUST
BE filed with the Department of Workers’ Claim WITHIN TWO YEARS of the date of
injury, or last payment of temporary total disability benefits.
NEED ASSISTANCE? Contact your employer’s claim representative. If your questions
about workers’ compensation rights are not promptly answered call THE KENTUCKY
DEPARTMENT OF WORKERS CLAIMS at 1-800-554-8601 to speak to an Ombudsman
or Workers’ Compensation Specialist.
EMPLOYER SUPERVISORS – NOTIFY MANAGEMENT IMMEDIATELY OF ALL
INJURIES SO THAT TIMELY REPORT CAN BE MADE AS REQUIRED BY LAW.
04/09/09

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