Revised 6/05 kentucky department of workers' claims application for Resolution of Coal Workers' Pneumoconiosis Claim Claim No




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Form 102-CWP


Revised 6/05 KENTUCKY

DEPARTMENT OF WORKERS' CLAIMS

Application for Resolution of Coal Workers' Pneumoconiosis Claim

Claim No. ___________________



. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Plaintiff


vs.


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. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Insurance Carrier


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Filed:
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Reason for Joinder:

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Other Defendant

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Street Address

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City/State/Zip Code

Reason for Joinder:

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I. Nature of Occupational Disease
1. Plaintiff states that on the ................................ day of ....……….............................., 20..........,

(day) (month) (year)

he/she became affected by coal workers' pneumoconiosis arising out of and in the course of his/or her employment.

2. State the date and means by which plaintiff gave notice of the injury to employer.

­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­________________________________________________________________________

3. Place of last exposure:___________________________________________

(city) (county) (state)

4. Nature of the work in which the plaintiff was engaged at the time of exposure

________________________________________________________________________
5. How did exposure to the disease occur? (Describe in detail)

________________________________________________________________________


II. Personal Data
6. Name and address of last school attended: ____________________________________

7. Highest grade completed in school: __________________________________________

8. GED awarded: _____ yes _____no

9. Professional or vocational degrees, certificates, or licenses: ________________________

________________________________________________________________________

10. Dependents: Name Social Security Number Relationship






































11. Has plaintiff previously filed a claim for Kentucky coal workers' pneumoconiosis benefits (including retraining incentive benefits)? ___yes ___no

If yes, give the date and defendant in previous claim: ___________________________

_______________________________________________________________________


III. Employment Data
12. Weekly wage at date of last exposure: _____________________________________

Attached copy of any proof wages, such as paycheck stub, W-2, etc.


13. Is plaintiff currently employed? ___ yes ___no

Name and address of current employer : _______________________________________

________________________________________________________________________
14. Is plaintiff still working in an environment where he/she is exposed to the hazards of the

disease ? ____ yes ____ no


15. Number of years of exposure to hazards of occupational disease________
16. Has plaintiff been exposed to the disease while working for more than one employer?

____ yes ____ no


17. Weekly wage currently earned: _________ Attach copy of any proof of current wages.
IV. Medical Data
18. List name and address of "B" reader whose report is attached to this Form. File original x-ray read by this "B" reader with this form.
Name of "B" Reader Address






19. Are you alleging a pulmonary impairment as the result of coal dust exposure?

_____ yes ______ no

If yes, attach results of pulmonary function studies and tracings.


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 of Attorney for Plaintiff
_______________________________

Name of Attorney (Print or Type)
_______________________________

Street Address

_______________________________


City/State/Zip Code



__________________________

Telephone Number

Instructions for


Completion of Forms 101, 102, 102-CWP and 103
Form 101 - Application for Resolution of Injury Claim
1. All sections of this form must be completed, and must be accompanied by the following:

a. Form 104 (Plaintiff's Employment History)

b. Form 105 (Plaintiff's Chronological Medical History)

c. Form 106 (Medical Waiver and Consent)

d. Medical report describing and supporting the injury which is the basis of the claim

e. Proof of Wages, including W-2's, paycheck stubs, etc.


2. All information must be typewritten.
3. File the original of this form and sufficient copies for all named defendants with the Department of Workers' Claims, Prevention Park, 657 Chamberlin Ave., Frankfort, Kentucky, 40601.
4. If you have no telephone number, please list a number at which you may be contacted.
5. If you have questions, call 1-800-554-8601.
Form 102 & Form 102-CWP - Application for Resolution of Occupational Disease Claim, and

Form 103 - Application for Resolution of Hearing Loss Claim
1. All sections of this form must be completed, and must be accompanied by the following:

a. Form 104 (Plaintiff's Employment History)

b. Form 105 (Plaintiff's Chronological Medical History)

c. Form 106 (Medical Waiver and Consent)

d. Medical report of "B" reader supporting the disease. (Applies to 102-CWP only)

e. Original x-ray read by "B" reader (Applies to 102-CWP only)

f. Pulmonary function studies and tracings if a pulmonary impairment is alleged

g. Proof of Wages, including W-2's, paycheck stubs, etc.



h. Social Security earnings record release form
2. This form may be filed in combination with an Application for Resolution of Injury Claim (Form 101) if both benefits are sought. Information provided should be current through the date application is signed by plaintiff.
3. All information must be typewritten.
4. File the original of this form and sufficient copies for all named defendants with the Department of Workers' Claims, Prevention Park, 657 Chamberlin Ave., Frankfort, Kentucky, 40601.
5. If you have questions, call 1-800-554-8601.
Note: Please list the correct name and address of the employer and insurance carrier to avoid delay in processing the claim.
Revised July, 2002


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