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KENTUCKY NO FAULT
IMPORTANT: A. TO ENABLE US TO DETERMINE IF YOU ARE ENTITLED TO BENEFITS, YOU MUST COMPLETE AND SIGN THIS FORM.
B. YOU MUST ALSO SIGN THE ATTACHED AUTHORIZATION (S).
C. RETURN PROMPTLY WITH ANY MEDICAL BILLS YOU HAVE RECEIVED TO DATE.
DATE DATE OF ACCIDENT
1. YOUR NAME HOME PHONE NUMBER BUSINESS PHONE NUMBER
2. YOUR ADDRESS (NO., STREET, CITY OR TOWN, STATE & ZIP CODE) DATE OF BIRTH SOCIAL SECURITY NO.
3. DATE AND TIME OF ACCIDENT PLACE OF ACCIDENT (STREET, CITY OR TOWN AND STATE)
A.M.
P.M.
4. BRIEF DESCRIPTION OF ACCIDENT
5. DO YOU OR ANY MEMBER OF YOUR HOUSEHOLD OWN A MOTOR VEHICLE? YES ڤ NO ڤ
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F “YES,” NAME OF INSURANCE COMPANY ____________________________________; POLICY NUMBER __________________________
W
ERE YOU THE DRIVER OF THE MOTOR VEHICLE? YES ڤ NO ڤ
WERE YOU A PASSENGER IN THE MOTOR VEHICLE? YES ڤ NO ڤ
WERE YOU A PEDESTRIAN? YES ڤ NO ڤ
WERE YOU A MEMBER OF THE MOTOR VEHICLE OWNER’S HOUSEHOLD? YES ڤ NO ڤ
HAVE YOU REJECTED THE LIMITATIONS ON YOUR RIGHT TO SUE AS
PROVIDED BY KENTUCKY NO-FAULT ACT (KRS 304.39)? YES ڤ NO ڤ
6. AS A RESULT OF THIS ACCIDENT, WERE YOU INJURED?
YES ڤ (IF YOUR ANSWER IS “YES”, COMPLETE THE REST OF THIS FORM.)
NO ڤ (IF “NO,” SIGN HERE AND REURN THIS FORM TO US.)
_
___________________________________________________________________ __________________________________
Signature Date
7. DESCRIBE YOUR INJURY
8. WERE YOU TREATED BY A DOCTOR? YES ڤ NO ڤ DOCTORS NAME AND ADDRESS
9. IF YOU WERE TREATED IN A HOSPITAL, WERE YOU AN HOSPITAL’S NAME AND ADDRESS
IN-PATIENT ڤ OUT-PATIENT ڤ
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0. AMOUNT OF MEDICAL BILLS TO DATE $________________________
WILL YOU HAVE MORE MEDICAL EXPENSE? YES ڤ NO ڤ
AT THE TIME OF YOUR ACCIDENT, WERE YOU IN THE COURSE OF YOUR EMPLOYMENT? YES ڤ NO ڤ
11. DID YOU LOSE WAGES OR SALARY AS A RESULT OF YOUR INJURY? YES ڤ NO ڤ
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F “YES,” AMOUNT LOST TO DATE $___________________________
WHAT IS YOUR AVERAGE WEEKLY WAGE OR SALARY? $_______________________
12. IF YOU LOST WAGES:
BEGINNING DATE OF DISABILITY FROM WORK: ____________________________ DATE RETUNED TO WORK __________________________
13. HAVE YOU RECEIVED OR ARE YOU ELIGIBLE FOR BENEFITS UNDER
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. ANY WORKMEN’S COMPENSATION LAW? YES ڤ NO ڤ
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F “YES,” AMOUNT: $___________________ PER WEEK ڤ PER MONTH ڤ
2. SOCIAL SECURITY BENEFITS? YES ڤ NO ڤ
