Agreement as to Compensation - Kentucky - Kentucky 2026

1. Click ‘Get Form’ to open the Agreement as to Compensation in the editor.
2. Begin by filling in the Plaintiff/Employee section, including your name, Social Security Number, and date of birth. Ensure all fields are completed accurately.
3. Next, provide details about the Insurer or Self-Insured party, including their mailing address. This is crucial for communication regarding your claim.
4. In the INJURY section, specify the date and location of the injury. Include a brief description of how it occurred and list any affected body parts.
5. Complete the MEDICAL INFORMATION section by detailing medical expenses paid and unpaid. Attach any necessary medical reports that support your claims.
6. Proceed to WORK INFORMATION and indicate if you qualify for increased benefits under KRS 342.730. Provide information about your job at the time of injury and subsequent employment details.
7. Fill out BENEFIT AND SETTLEMENT INFORMATION carefully, ensuring all calculations are accurate for any lump sums or income benefits agreed upon.
8. Finally, review all sections for completeness before signing. If waiving medical benefits, acknowledge this by signing where indicated.

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