Open Records Request - Department Of Workers' Claims printable pdf download

Open Records Request - Department Of Workers' Claims

Commonwealth of Kentucky

Department of Workers’ Claims

657 Chamberlin Ave

Frankfort, KY 40601

Phone: 502-564-5550

Fax: 502-564-5732

Email: KYWCOPENREC@ky.gov

03/2011

Open Records Request

Date________________

Requestor’s Name__________________________

Company Name____________________________

Phone Number______________________________

Address____________________________________

____________________________________

Email Address:___________________________________

Claimant Name__________________________________

Claim Number___________________________________

SSN_____________________________________________

Items Requested

Entire File

Only Claim # provided above

First Report Only

Other: ______________________________

_______________________________________

Signature: ____________________________________

Please note all records requests require pre-payment. A cost estimate will be mailed in 1-3 business

days of receipt of your request. Records will be mailed once payment is received. Records are not

faxed or electronically transferred.

**Please note effective October 11, 2010 there will be a $35.00 fee on all returned checks.

**Information provided by the Dept. of Workers’ Claims is only as accurate as the data submitted to

us by the insurance carriers.

Open Records Request - Department Of Workers' Claims