Download Kentucky 5 Template
Contents
Steps to Filling Out Kentucky 5
Completing the Kentucky 5 form is a straightforward process. This form allows an employee to withdraw a previous notice of rejection regarding workers' compensation coverage. After filling out the form, it needs to be submitted to the employer and the original sent to the Department of Workers Claims for processing.
- Begin by entering the employer's federal ID number in the designated space.
- Next, write the employer's name clearly.
- Provide the employer's phone number.
- Fill in the employer's street address, ensuring all details are accurate.
- Enter the city, state, and ZIP code for the employer's location.
- Specify the nature of the business conducted by the employer.
- Indicate the number of employees working for the employer.
- Now, turn to the employee data section. Write the employee's name.
- Fill in the employee's social security number.
- Provide the employee's street address.
- Enter the employee's phone number.
- Complete the city, state, and ZIP code for the employee's address.
- State the effective date of the withdrawal notice.
- Record the date when the rejection notice was originally filed with the Department of Workers Claims.
- Sign the form as the employee and write the date of signing.
- Have the notary public complete the acknowledgment section, including their signature and commission expiration date.
- In the acknowledgment of receipt and filing section, the employer should write their name and the date the withdrawal was filed.
- Finally, the employer's title and date should be filled in.
Dos and Don'ts
When filling out the Kentucky 5 form, it is essential to approach the process with care and attention to detail. Below are some important do's and don'ts to keep in mind.
- Do ensure that all information is accurate and complete.
- Do use clear and legible handwriting if filling out the form by hand.
- Do sign and date the form in the designated areas.
- Do provide a self-addressed stamped envelope if you wish to receive confirmation of filing.
- Do send the original form to the correct address: Department of Workers Claims, 1270 Louisville Road, Frankfort, Kentucky 40601.
- Don't forget to include your employer's Federal ID number.
- Don't leave any sections of the form blank; fill in all required fields.
- Don't submit the form without reviewing it for errors.
- Don't assume that verbal communication with your employer is sufficient; always submit the written notice.
File Breakdown
| Fact Name | Details |
|---|---|
| Form Purpose | The Kentucky 5 form is used by employees to withdraw a previously filed notice of rejection regarding workers' compensation coverage. |
| Governing Law | This form is governed by the Kentucky Revised Statutes Chapter 342, known as the Workers’ Compensation Act. |
| Filing Requirement | Employees must file the original form with their employer and mail it to the Department of Workers Claims. |
| Withdrawal Effectiveness | The withdrawal of notice is effective only after one week from the date it is filed with the employer. |
| Employer Information | The form requires detailed employer information, including the federal ID number, name, and nature of business. |
| Employee Information | Employees must provide their name, social security number, and contact details on the form. |
| Notary Requirement | The employee's signature must be notarized to confirm the voluntary act of withdrawal. |
| Acknowledgment of Receipt | Employers must acknowledge receipt of the withdrawal form and file it with the Department of Workers Claims. |
| Contact Information | For questions, employees can contact the Enforcement Branch at (800) 731-5241. |
Documents used along the form
The Kentucky 5 form is a crucial document for employees wishing to withdraw their written notice of rejection from workers' compensation coverage. Alongside this form, several other documents may be necessary to ensure compliance with Kentucky's workers' compensation laws. Below is a list of related forms that are commonly used in conjunction with the Kentucky 5 form.
- Kentucky Form 4: This is the initial notice of rejection that an employee submits to decline workers' compensation coverage. It outlines the employee's decision and serves as the basis for any subsequent withdrawal.
- Kentucky Form 2: This form is used to report an injury or occupational disease to the employer. It details the circumstances of the injury and is essential for initiating a workers' compensation claim.
- Kentucky Form 101: This is the application for income benefits. Employees complete this form to request compensation for lost wages due to a work-related injury.
- Kentucky Form 111: This document is used to file a claim for permanent partial disability benefits. It provides information about the employee's condition and the impact on their ability to work.
- Last Will and Testament: This essential document governs the distribution of a person's assets after their passing, ensuring their final wishes are honored. For more information, visit smarttemplates.net/.
- Kentucky Form 104: This form is the "Notice of Claim" and is submitted to notify the Kentucky Department of Workers' Claims about a work-related injury or illness. It ensures that the claim is officially recognized.
- Kentucky Form 113: This form is used to appeal a decision made by the Department of Workers' Claims regarding a claim. Employees who disagree with a ruling can use this form to seek further review.
- Kentucky Form 116: This is the "Request for Hearing" form. It is submitted to request a hearing if there are disputes about benefits or other aspects of a workers' compensation claim.
Using these forms correctly can streamline the process of managing workers' compensation claims in Kentucky. Each document plays a specific role in ensuring that both employees and employers adhere to the state's regulations. Familiarity with these forms can help facilitate a smoother experience for all parties involved.
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FAQ
What is the Kentucky 5 form used for?
The Kentucky 5 form, also known as the Written Notice of Withdrawal, is used by employees to withdraw their previous notice of rejection of workers' compensation coverage. By submitting this form, an employee indicates their desire to be covered under the Kentucky Workers' Compensation Act, effectively reversing their earlier decision to reject coverage.
Who needs to fill out the Kentucky 5 form?
Any employee who has previously submitted a notice of rejection regarding workers' compensation coverage must fill out the Kentucky 5 form if they wish to withdraw that rejection. This includes providing personal information such as the employee's name, Social Security number, and details about their employer.
How does an employee submit the Kentucky 5 form?
The employee must complete the form with all required information and sign it. Afterward, they should submit the original form to their employer. The employer is then responsible for filing the form with the Department of Workers Claims at the specified address. To ensure acknowledgment of the filing, the employee may include a self-addressed stamped envelope along with a photocopy of the form.
When does the withdrawal take effect?
The withdrawal of the notice of rejection becomes effective one week after the Kentucky 5 form is filed with the employer. This means that if an employee has sustained an injury or incurred a disease within that one-week period, the withdrawal may not be applicable for those incidents.
What should an employee do if they have questions about the Kentucky 5 form?
If an employee has any questions regarding the Kentucky 5 form or the withdrawal process, they should contact the Enforcement Branch of the Department of Workers Claims. The office can be reached at (800) 731-5241 for assistance and clarification on any concerns related to the form or workers' compensation coverage.