Claim No. Form 101IR October 2016 Edition KENTUCKY DEPARTMENT OF WORKERS’ CLAIMS Filed: 657 CHAMBERLIN AVENUE, FRANKFORT, KY 40601 Application for Resolution Interlocutory Relief – Defendant/Employer Plaintiff Mailing Address Social Security Number/Green Card City/State/Postal Code Birth Date Gender Insurance Carrier Mailing Address Mailing Address City/State/Postal Code City/State/Postal Code Additional Defendant Name Outside United States Mailing Address Country City/State/Postal Code Reason for Joinder Additional Other Defendant Mailing Address City/State/Postal Code
Form 101IR October 2016 Edition KENTUCKY DEPARTMENT OF WORKERS’ CLAIMS 657 CHAMBERLIN AVENUE, FRANKFORT, KY 40601 Claim No. Filed: Application for Resolution – Interlocutory Relief Plaintiff Defendant/Employer Social Security Number/Green Card Mailing Address Birth Date Gender City/State/Postal Code Insurance Carrier Mailing Address Mailing Address City/State/Postal Code City/State/Postal Code Additional Defendant Name Outside United States Country Mailing Address City/State/Postal Code Reason for Joinder Additional Other Defendant Mailing Address City/State/Postal Code