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In the realm of workers' compensation in Kentucky, navigating the complexities of forms and regulations can be daunting for employees and employers alike. One critical document in this process is the Kentucky 5 Form, formally known as the Written Notice of Withdrawal. This form is utilized when an employee decides to withdraw their previously filed rejection of workers’ compensation coverage, signaling a change in their intention to claim benefits under the Kentucky Revised Statutes Chapter 342. Key information required within this document includes the employer's data—such as federal ID, name, contact information, and details about the nature of the business—as well as the employee's particulars, including their name, social security number, and address. The form also necessitates a declaration of the effective date of withdrawal, the initial date the rejection notice was filed, and requires the employee's signature, ensuring personal acknowledgment of these changes. It emphasizes the importance of timely filing, as it outlines that a withdrawal only becomes effective after a waiting period of at least one week following the notice's submission. Furthermore, employers are tasked with filing the original form with the Department of Workers Claims, reinforcing the process. For those seeking confirmation of their withdrawal, additional steps must be taken, including submitting a self-addressed stamped envelope along with a photocopy of the form.

Kentucky 5 Example

FORM NO. 5

WRITTEN NOTICE OF WITHDRAWAL (REV. 7/97)

DEPARTMENT OF WORKERS CLAIMS

1270 LOUISVILLE ROAD

FRANKFORT, KENTUCKY 40601

WRITTEN NOTICE OF WITHDRAWAL OF FORM 4 REJECTION

EMPLOYER DATA:

FEDERAL ID# _____________________________

EMPLOYER NAME ____________________________________________________ PHONE NO. ________________________

STREET ADDRESS __________________________________________________________________________________________

CITY, STATE, ZIP ___________________________________________________________________________________________

NATURE OF BUSINESS ____________________________________

#OF EMPLOYEES ________________________________

EMPLOYEE DATA:

NAME ______________________________________ SOCIAL SECURITY NUMBER _________________________________

STREET ADDRESS ______________________________________________ EMPLOYEE PHONE NO. ____________________

CITY, STATE, ZIP ___________________________________________________________________________________________

I HEREBY WISH TO NOTIFY THE ABOVE LISTED EMPLOYER THAT I WISH TO WITHDRAW MY EMPLOYEE’S WRITTEN NOTICE OF REJECTION EFFECTIVE__________________________. THE REJECTION NOTICE WAS FILED WITH THE DEPARTMENT OF WORKERS

CLAIMS ON OR ABOUT_________ (YEAR). I NOW WISH TO BE COVERED UNDER THE PROVISIONS OF THE KENTUCKY REVISED

STATUTES CHAPTER 342, COMMONLY KNOWN AS THE WORKERS’ COMPENSATION ACT. I HAVE FILED THIS FORM WITH MY EMPLOYER ON THIS DATE.

 

_____________________________________________________________

 

EMPLOYEE SIGNATURE

DATE

STATE OF ______________________

 

 

COUNTY OF ____________________

 

 

SUBSCRIBED AND SWORN TO BEFORE ME BY ___________________________________________________ TO BE

 

 

EMPLOYEE NAME

 

HIS/HER VOLUNTARY ACT AND DEED, ON THIS______________DAY OF______________________________ , _________.

 

____________________________________

________________________________________

 

NOTARY PUBLIC

MY COMMISSION EXPIRES:

 

ACKNOWLEDGMENT OF RECEIPT AND FILING

I,_______________________________________________________HEREBY ACKNOWLEDGE THAT THE ABOVE-MENTIONED EMPLOYEE

FILED THIS WITHDRAWAL OF THE NOTICE OF REJECTION WITH HIS/HER EMPLOYER ON THE __________________________DAY OF

_________________, _________, AND THAT THE ORIGINAL OF THIS FORM WAS MAILED TO THE DEPARTMENT OF WORKERS CLAIMS

ON THIS DATE.

BY: ___________________________________________________________________________

EMPLOYER

TITLE

DATE

INSTRUCTIONS FOR WITHDRAWAL OF

EMPLOYEE’S WRITTEN NOTICE OF REJECTION

Pursuant to KRS 342.395(3), withdrawal of the notice of rejection shall not be effective as to any injury sustained or disease incurred less than one (1) week after notice is filed with the employer.

The employer must file the original of this form with the Department of Workers Claims. Forms should be mailed to: Department of Workers Claims, ATTENTION: Enforcement

Branch, 1270 Louisville Road, Frankfort, Kentucky 40601.

If you want to have the filing of the withdrawal acknowledged by the Department, you must forward with the original, a photostatic copy and a self-addressed stamped envelope.

If you have any questions, please contact the Enforcement Branch at (800) 731-5241.

Get Kentucky 5 PDF Form

Form Characteristics

Fact Name Description
Purpose The Kentucky 5 form is used to withdraw a previously filed notice of rejection related to workers' compensation claims.
Governing Law This form is governed by Kentucky Revised Statutes (KRS) Chapter 342, the Workers’ Compensation Act.
Filings Requirement Employers must file the original form with the Department of Workers Claims after an employee submits it.
Acknowledgment To confirm the withdrawal, employers should send a self-addressed stamped envelope with the form for acknowledgment by the Department.
Waiting Period Withdrawal of the rejection notice becomes effective one week after it is filed with the employer.

Guidelines on Utilizing Kentucky 5

Completing the Kentucky 5 form requires careful attention to detail. After filling it out, you will submit it to your employer, who is responsible for forwarding it to the appropriate department. This ensures that your withdrawal request is processed correctly and in a timely manner.

  1. Begin by entering the employer's information at the top of the form. Fill in the Federal ID#, Employer Name, Phone Number, Street Address, City, State, ZIP, the Nature of Business, and the Number of Employees.
  2. Next, fill in the employee's information. Include the Name, Social Security Number, Street Address, Employee Phone Number, and City, State, ZIP.
  3. Indicate the effective date for the withdrawal of the written notice of rejection:
  4. On the line provided, write the date the original rejection notice was filed with the Department of Workers Claims.
  5. Sign and date the form where indicated to confirm your wish to withdraw the notice.
  6. Get the form notarized. A notary public will need to witness your signature and complete their section.
  7. Have the employer acknowledge receipt of the notice by filling out their section at the bottom of the form.
  8. Make sure to retain a copy of the completed form for your records.
  9. Finally, send the original form to the Department of Workers Claims at the address provided. If you want confirmation of receipt, include a copy of the form and a self-addressed stamped envelope.

What You Should Know About This Form

What is the purpose of the Kentucky 5 form?

The Kentucky 5 form serves as a Written Notice of Withdrawal for an employee who previously rejected their workers' compensation coverage. By submitting this form, the employee indicates a desire to withdraw that rejection and become covered under the provisions of the Kentucky Workers’ Compensation Act. This notice is crucial for ensuring that the employee has the necessary coverage for any work-related injuries or diseases.

How should I fill out the Kentucky 5 form?

To complete the Kentucky 5 form, accurate information must be provided, including both employer and employee data. This information includes the employer's federal identification number, name, contact details, and nature of business, as well as the employee's name, Social Security number, and address. The employee must also clearly specify the date they are withdrawing their notice of rejection and the date the original rejection notice was filed. Finally, the employee must sign and date the form to affirm their request. A notary public will need to witness the employee’s signature, which adds an official layer to the process.

What happens after I submit the Kentucky 5 form?

Once the Kentucky 5 form is completed and submitted to the employer, it is the employer's responsibility to file the original form with the Department of Workers Claims. This is a vital step, as the withdrawal of the rejection will not take effect until the employer has filed the form. The employee should allow at least one week from the date of filing for the withdrawal to become effective, particularly if it relates to a specific injury or disease. To keep a record of the submission, it is advisable for the employee to keep a copy of the form for their own records.

Can I obtain confirmation of my withdrawal?

If an employee wishes to receive confirmation that their withdrawal has been filed with the Department of Workers Claims, they should include a self-addressed stamped envelope along with a photocopy of the Kentucky 5 form when sending it. This allows the department to return a copy, acknowledging receipt of the withdrawal. Keeping documentation is important for both the employee and employer, as it ensures there is a clear record of the withdrawal request.

Common mistakes

Filling out the Kentucky 5 form can be straightforward if proper attention is paid to details. However, there are common mistakes people make that can hinder the process. One significant error is failing to provide complete employer information. Each field, including the Federal ID number and employment details, must be filled out accurately. Missing this information can cause delays in processing the withdrawal.

Another frequent mistake is neglecting the employee data section. It’s essential to include the employee's full name and social security number without errors. Inaccurate or incomplete data may lead to questions or rejections, impacting the employee’s coverage under the Kentucky Workers’ Compensation Act.

Many individuals also overlook the dates required in the form. The effective date must be clearly stated, and the date when the rejection notice was filed is vital too. If either date is missing or incorrect, it can create confusion about coverage and withdraw eligibility.

Additionally, signatures play a crucial role in the submission process. Employees must ensure they sign the form correctly. The notary section must also be filled out accurately, containing the notary public's signature and commission expiration. Missing or incorrect signatures can invalidate the form.

Lastly, individuals often forget about submitting the original form and acknowledging the filing correctly with the Department of Workers Claims. Sending in just a copy, without the required original, may result in processing delays. Including all necessary documents, especially a self-addressed stamped envelope for acknowledgment, is important to ensure a smooth process.

Documents used along the form

When dealing with workers' compensation in Kentucky, various forms and documents may accompany the Kentucky 5 form. Understanding the purpose of these documents is crucial for both employers and employees in navigating the claims process effectively.

  • Kentucky Form 4: This form is the initial written notice of rejection submitted by an employee who is opting out of a workers' compensation policy. It outlines the employee's reasons for rejection and serves as the starting point in the claims process.
  • Kentucky Form 6: Known as the Notice of Injury or Illness, this form is completed by employees to formally report an injury or illness sustained while on the job, serving as an essential part of the claims documentation.
  • Kentucky Form 3: This document provides information related to the Employer's First Report of Injury. Employers must file this report with the Department of Workers' Claims to document workplace injuries and begin the claims process.
  • Kentucky Form 45: This is a Request for Hearing form filed by either the employee or employer if a dispute arises regarding the workers' compensation claim, allowing for a formal review of the case by the Kentucky Labor Cabinet.
  • Kentucky Form 12: This is a Notice of Waiver that may be filed by the employer if they choose to waive certain rights related to the workers' compensation claim, requesting the employee acknowledge their understanding of the waiver.
  • Kentucky Form 7: Also known as the Permanent Total Disability Application, this form is used when an employee claims to have sustained a permanent disability that prevents them from returning to work.
  • Kentucky Form 15: This form, the Application for Surgical or Medical Services, is completed when an employee seeks approval for medical treatment or services related to a work injury.
  • Kentucky Form 35: This is the Employee’s Application for a Lump Sum Settlement form, which employees use to request a one-time payment to settle their workers' compensation claim.
  • Kentucky Form 21: The Request for Reimbursement for Out-Of-Pocket Expenses is used by employees to seek reimbursement for any medical costs incurred due to a work-related injury.
  • Kentucky Form 8: This Employer’s Notice of Reinstatement of Workers’ Compensation Benefits is filed by the employer when they are reinstating benefits after previously having been denied or suspended.

Each of these documents plays a distinct role in the process surrounding workers' compensation claims. Proper completion and submission of these forms are vital for ensuring compliance with Kentucky's legal requirements and safeguarding the rights of both employees and employers.

Similar forms

  • Form 4 - Notice of Rejection: This document is filed by an employee to officially reject coverage under the Workers' Compensation Act. It serves as the initial communication, while the Kentucky 5 form allows for the withdrawal of that rejection.

  • Form 111 - Claim for Benefits: This form is used by an employee to file a claim for workers' compensation benefits. Both forms are related as they both deal with the employee's status regarding workers' compensation, but the Kentucky 5 form specifically focuses on the withdrawal of a rejection.

  • Form 19 - Notice of Injury: Similar to the Kentucky 5 form, this document informs the employer and the Department of Workers Claims about an injury. However, the Kentucky 5 form addresses the withdrawal of a previous rejection, clarifying an employee's desire to seek benefits.

  • Form 101 - Application for Adjustment of Claim: This form is submitted for formal requests to adjust an existing claim. While the Kentucky 5 form is about retracting a rejection, the Form 101 serves to address and modify the claim process.

  • Form 114 - Employer's Report of Injury: This report is filled out by the employer to document injuries in the workplace. Both forms interact within the workers' compensation system, but the Kentucky 5 specifically allows an employee to rescind a rejection.

  • Form 525 - Application for Reinstatement: After a rejection, an employee may later seek reinstatement to benefits. The Kentucky 5 form can be seen as a preliminary step toward regaining those benefits by withdrawing a prior rejection.

Dos and Don'ts

When filling out the Kentucky 5 form, consider the following do's and don'ts:

  • Do ensure all your information is accurate and complete. Missing details can cause delays.
  • Do double-check the effective date of your withdrawal to ensure compliance with state requirements.
  • Do provide a self-addressed stamped envelope if you wish to receive confirmation of your filing.
  • Do keep a copy of the submitted form for your records and future reference.
  • Don't submit the form without a notary's signature if it requires notarization. This could invalidate your request.
  • Don't forget to mail the original form to the Department of Workers Claims. Failure to do so may jeopardize your withdrawal.
  • Don't delay filing beyond the given timeframe, as this may affect your eligibility for workers' compensation.
  • Don't assume that verbal notifications are sufficient. Always use the form as a formal notice.

Misconceptions

Understanding the Kentucky 5 form can be challenging. There are some common misconceptions that may cause confusion. Here are nine of them:

  • This form can be used for any kind of workers’ compensation claim. The Kentucky 5 form specifically applies to the withdrawal of a notice of rejection from a workers' compensation claim. It is not a general claim form.
  • You do not need to file this form with your employer. Filing with the employer is necessary for the withdrawal to take effect. The original must be submitted for proper processing.
  • A withdrawal is immediately effective. A withdrawal is not effective until after one week from the filing date, at which point it becomes official.
  • Only employers handle the notification process. Employees also have responsibilities in this process. They must ensure the form is filed correctly and on time.
  • You can ignore the details in the form. All information, including names and dates, must be accurately filled out. Missing information can delay the process.
  • The employer automatically receives confirmation upon filing. To receive acknowledgment, employees must send a self-addressed stamped envelope along with a copy of the form.
  • Filing via email is acceptable. The form must be mailed in with original signatures. Email submissions are not allowed.
  • Anyone can complete the form for the employee. Only the employee can withdraw their notice of rejection; this ensures it reflects their voluntary decision.
  • All notary public requirements are optional. The form must be notarized to prove the employee’s identity and the authenticity of their signature.

Clarifying these misconceptions may help ensure a smoother process for anyone dealing with workers' compensation claims in Kentucky.

Key takeaways

Here are key takeaways about the Kentucky 5 form for withdrawing a notice of rejection:

  • The Kentucky 5 form is used by an employee to withdraw a previously filed notice of rejection.
  • The form must include accurate employer and employee information, including names, addresses, and contact numbers.
  • The withdrawal notice is not effective for any injury or disease that occurred less than one week after filing.
  • Submission of the original form is required to the Department of Workers Claims for it to be valid.
  • For acknowledgment of receipt by the Department, include a photocopy of the form and a self-addressed stamped envelope with the original.
  • If assistance is needed, contact the Enforcement Branch at (800) 731-5241.

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