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.
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EMPLOYEE SIGNATURE |
DATE |
STATE OF ______________________ |
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COUNTY OF ____________________ |
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SUBSCRIBED AND SWORN TO BEFORE ME BY ___________________________________________________ TO BE |
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EMPLOYEE NAME |
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HIS/HER VOLUNTARY ACT AND DEED, ON THIS______________DAY OF______________________________ , _________. |
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____________________________________ |
________________________________________ |
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NOTARY PUBLIC |
MY COMMISSION EXPIRES: |
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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: ___________________________________________________________________________
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.
