Kentucky Required Postings and Forms
- Workers’ Compensation State Posting Notice
- Hospital Emergency Worksite Poster
- Sample Copies of the EMP KY MHCP Employee Notices
Anti-Fraud Notice
Please print and post the following notices, both in English and Spanish, in a conspicuous location frequented by employees, such as the break room, lunch room or time clock. If you have multiple business locations, be sure to post the notices at each location.
Please print and review the following forms with your current staff (and new employees at time of hire):
- Initial Employee Letter and Acknowledgement Form. Employers should send the “Initial Employee Letter and Acknowledgement Form” to each employee. These documents should also be given to any new hires. The documents can be sent in any format (e.g. presentation, email, etc.). Each employee must sign the Acknowledgement form and return it to a key individual at the employer’s location. This form should be placed in the employee’s personnel file, acknowledging receipt of the information packet.
The following forms need to be completed and submitted to EMPLOYERS when a work-related injury occurs:
- 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. You must use this form to notify EMPLOYERS of every work-related injury or disease suffered by an employee, regardless of severity. Alternatively, you may also call the EMPLOYERS Injured Employee Hotline at 855-365-6010. The Injured Employee Hotline provides immediate access to registered nurses using national guidelines to provide initial medical guidance over the phone and immediate reporting of injuries with less paperwork.
- Form 106 Medical Waiver and Consent. This is a medical authorization form that enables you or the Division of Workers’ Compensation to obtain medical information relative to your employee’s work-related injury/occupational disease. This form needs to be completed, signed and submitted to EMPLOYERS by your employee.
- Form 113 Notice of Designated Physician. This notice identifies the designated physician. You need to complete the form and return it to EMPLOYERS within 10 days from the start of treatment.
- AWW-1 Wage Statement. This form enables us to calculate the correct compensation that may be owed to an injured employee. Please complete the form and submit it to EMPLOYERS within five days after your knowledge of any accident that has caused your employee to be disabled for seven calendar days or more.
- First Fill Form. This form provides your employees with basic information about our Pharmacy Benefit Program, including such things as the phone number to call to locate a First Fill participating pharmacy. When your employee becomes injured, please print and complete this form and provide it to your injured employee. Your employee will need to provide this completed form along with the prescription for his/her work-related injury or occupational disease to the pharmacist. Using this form will help enable quick authorization for your employee’s initial medication and ensure that the initial prescription is provided at no cost to the injured employee.
- Accident Investigation Report. This basic accident form should be completed by the employee’s supervisor/manager as soon as possible after the accident. Please send the report to the following EMPLOYERS address as soon as it has been completed by the supervisor/manager: EMPLOYERS Claim Department, P.O. Box 14791, Lexington, KY 40512-4791. You should also keep a copy on file for your records.
- EMP KY MHCP Employee Channeling Letter. The Channeling Letter will assist the injured employee in locating a physician.
More Kentucky Workers’ Comp Resources
- Off-Site Transitional Duty Program – Helping Your Injured Employees Get Back to Work. A successful transition back to work relies on the collaborative efforts of the manager/supervisor, the injured employee and their adjuster. As a manager/supervisor, learn what you can do to help facilitate a successful return to work.