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IA-1 WORKERS COMPENSATION - FIRST REPORT OF INJURY OR ILLNESS Employer Name Address Including Zip Report Purpose Code Carrier/Administration Claim Number Jurisdiction Insured Report Number KY Location Employer s Location Address if different SIC Code Employer FEIN Phone Carrier/Claims Administrator Claims Administrator Name Address Phone No Policy Period Kentucky Employers Mutual Ins. Lexington Financial Center 250 W. Main Street Suite 900 Lexing...

How to fill out form ia 1

How to fill out Kentucky first report of:

1. Obtain the necessary form: The Kentucky first report of can be obtained from the Kentucky Department of Workers' Claims website or from the employer's insurance provider.
2. Provide accurate information: Fill out the form with accurate information about the injured employee, including their name, address, and social security number.
3. Describe the incident: Clearly describe the details of the incident that led to the employee's injury, including the date, time, and location of the incident.
4. Provide medical information: Include information about any medical treatment the employee has received for their injury, including the name of the treating physician or medical facility.
5. Report wage information: Include the employee's wage information, including their average weekly wage at the time of the injury.
6. Sign and submit: Once the form is filled out completely, sign it and submit it to the appropriate party as indicated on the form.

Who needs Kentucky first report of:

1. Employers: Employers in Kentucky are required by law to report any work-related injuries or illnesses to the Kentucky Department of Workers' Claims.
2. Insurance providers: Insurance providers need the Kentucky first report of to process workers' compensation claims and determine the appropriate coverage and benefits for the injured employee.
3. Injured employees: Injured employees may also need the Kentucky first report of to ensure that their injury is properly reported and documented for workers' compensation purposes.

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Instructions and Help about kentucky workers' compensation forms

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People Also Ask about

What is timely filing for workers comp in Kentucky?

Time Limits for Filing KY Workers' Comp Claims Written claims for workers' compensation benefits need to be filed with the Department of Workers' Claims. These claims must be filed within two years of the date of injury or last voluntary payment of disability benefits.

What is the statute of limitations on a workplace injury in Kentucky?

The statute of limitations for Kentucky workers' compensation claims is two years. You must file your claim within two years of either sustaining a work-related injury in an accident or discovering the injury.

How long does an employee have to report an injury in Kentucky?

Requirements for Filing In Kentucky, you must report your workplace injury within three days of it occurring. This is known as the "First Report of Injury" and is typically required for workers' compensation insurance.

What is the first report of injury form for workers comp in Kentucky?

Form 1A-1 First Report of Injury (FROI). As soon as you have been notified of a work-related injury, please fill out this form and submit it to EMPLOYERS. This form must be completed within 10 days from notice of an accident. Fatalities must be reported within 24 hours.

How do I file a workers comp claim in KY?

To file for workers' compensation in Kentucky, you will need to submit an Application for Resolution of a Claim, which will then be reviewed by the Division of Claims Processing. Your application will be assigned to an Administrative Law Judge based on your county of residence.

What must the first report of injury contain?

The Employer's First Report of Injury or Illness provides information on the claimant, employer, insurance carrier and medical practitioner necessary to begin the claims process. Details of the claimant's employment and circumstances surrounding the injury or illness are also requested.

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What is kentucky first report of?

I couldn't find a specific reference to "Kentucky First Report." Could you please provide more information or context?

Who is required to file kentucky first report of?

The Kentucky First Report of Injury or Illness must be filed by an employer, insurer, or a self-insured entity when an employee sustains a work-related injury or illness.

How to fill out kentucky first report of?

To accurately fill out the Kentucky First Report of Injury or Occupational Disease (Form 344), follow these steps: 1. Obtain a copy of the form: You can find the Kentucky First Report of Injury or Occupational Disease form on the Kentucky Department of Workers' Claims website. Download and print the form. 2. Section 1 (Employer/Insurer Information): Fill in the details of the employer or insurer. This includes the company name, policy number, address, phone number, and contact person. 3. Section 2 (Employee Information): Provide information about the employee who suffered the injury or occupational disease. Include their full name, address, social security number, job title, date of birth, gender, and date of hire. 4. Section 3 (Date, Time, and Place of Injury): Specify the exact date, time, and location where the injury or occupational disease occurred. If unknown, write "UNKNOWN" and provide the best available information. 5. Section 4 (Description of Injury/Occupational Disease): Write a detailed account of how the injury/occupational disease occurred, including the body parts affected, the nature and extent of the injury, and any contributing factors. Use additional pages if necessary. 6. Section 5 (Employer Information): Provide details about the injured employee's supervisor, including their name, phone number, and email address. 7. Section 6 (Witness Information): If any witnesses were present during the injury/occupational disease, provide their names, phone numbers, and addresses. 8. Section 7 (Health Care Provider Information): Fill in the name, address, phone number, and email address of the healthcare provider who treated the employee. 9. Section 8 (Lost Time): Indicate whether the employee lost any time from work as a result of the injury/occupational disease. If so, provide the dates of absence. 10. Section 9 (Medical Expenses): Specify any medical expenses or bills related to the injury/occupational disease. 11. Section 10 (Compensation Information): Provide information regarding any compensation already paid to the employee, including dates and amounts. 12. Section 11 (Additional Comments): Include any additional information or comments that may be relevant to the injury/occupational disease case. 13. Section 12 (Employer/Insurer Authorization): The employer or insurer must sign and date the form to authorize its completion. 14. Section 13 (Employee Certification): The injured employee must also sign and date the form to certify the accuracy of the information provided. 15. Section 14 (Notary Public): If required by the Kentucky Department of Workers' Claims, the form needs to be notarized. 16. Submit the form: After completing and reviewing the form, make copies for your records and submit the original to the Kentucky Department of Workers' Claims. Follow their specific instructions for submission, which may include mailing or faxing the form. Remember to consult the Kentucky Department of Workers' Claims website or contact their office directly for any specific instructions or requirements before submitting the form.

What is the purpose of kentucky first report of?

The purpose of Kentucky's first report is not specific enough to determine its context or meaning. It would be helpful to provide additional details or clarify the subject matter the report pertains to.

What information must be reported on kentucky first report of?

The Kentucky First Report of Injury requires the following information to be reported: 1. Employer Information: - Name and address of the employer - The Federal Employer Identification Number (FEIN) or Social Security Number (SSN) of the employer - Contact information of the employer (phone number, email, etc.) 2. Employee Information: - Name, address, and Social Security Number (SSN) of the injured employee - Employee's date of birth and gender - Contact information of the employee (phone number, email, etc.) 3. Injury Details: - Date and time of the accident or injury - Location/address where the injury occurred - Description of how the injury occurred - Nature of the injury or illness (e.g., sprain, fracture, burn, etc.) - Body part(s) injured or affected 4. Medical Treatment: - Name and contact information of the treating healthcare provider(s) - Description of the medical treatment received - Date of the first treatment for the injury 5. Lost Time and Wage Information: - Date the employee lost time from work due to the injury - Number of days/hours the employee will be/was unable to work - Employee's average daily wage or earning rate - Any compensation or benefits provided to the employee during the injured period 6. Signature and Certification: - Authorized representative of the employer must sign and certify the report, affirming the accuracy of the information provided. It is important to note that these requirements may vary slightly depending on the specific form used and any changes in the state's reporting requirements. It is recommended to refer to the official Kentucky First Report of Injury form or consult with the Kentucky Labor Cabinet for the most up-to-date and accurate information.

What is the penalty for the late filing of kentucky first report of?

The penalty for the late filing of Kentucky's First Report of Injury (Form 101) is a fine of up to $250 for each offense. Additionally, failure to file the report may result in the suspension of the employer's workers' compensation insurance coverage until the report is filed.

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