Forms & Paperwork

Form MTR-2
Motion to Reopen KRS 342.732 Benefits
Form 110-CWP
Agreement as to Compensation and Order Approving Settlement for Coal Workers Pneumoconiosis
Form 102-CWP
Application for Resolution of Coal Workers' Pneumoconiosis Claim
Educational Release Form
Authorization for Release of Educational Information
Form IA-1
Workers Compensation - First Report of Injury or Illness
Form IA-2
Workers Compensation - Subsequent Report
Form Hearing Loss Stipulation
Workers Compensation - Hearing Loss Stipulation
Form Injury Stipulation
Workers Compensation - Injury Stipulation
Form Occupational Disease Stipulation
Workers Compensation - Occupational Disease Stipulation
Form 101
Application for Resolution of Injury Claim
Form 102
Application for Resolution of Occupational Disease Claim
Form 103
Application for Resolution of Hearing Loss Claim
Form 104
Plaintiff's Employment History
Form 105
Plaintiff's Chronological Medical History
Form 106
Medical Waiver and Consent
Form 107-I
Physician's Medical Report-Injury
Form 107-P
Physician's Medical Report-Psychological
Form 108-CWP
Physician's Medical Report-Occupational Disease
Form 108-HL
Physician's Medical Report-Hearing Loss
Form 108-OD
Physician's Medical Report-Occupational Disease
Form 109
Attorney Fee Election
Form 110-I
Agreement as to Compensation and Order Approving Settlement - Injury
Form 110-O
Agreement as to Compensation and Order Approving Settlement - Occupational Disease
Form 111-I-HA
Notice of Claim Denial or Acceptance-Injury and Hearing Loss
Form 111-OD
Notice of Claim Denial or Acceptance-Occupational Disease
Form 112
Medical Fee Dispute
Form 113
Notice of Designated Physician
Form 114
Request for Payment for Services or Reimbursement for Compensable Expenses
Form 115
Social Security Release Form
Form AWW-1
Average Weekly Wage Certification
Form 150
Workers Compensation Statistical Report
Form 375
Application for Split Coverage
Form 375 EL
Application for Split Coverage (Employee Leasing)
Form 375 Wrap-Up
Application for Split Coverage (Wrap-Up)
Form 11
Motion to Substitute Party and Continuation of Benefits
Manual Change Form
Manual Change Form