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Kentucky form 4 waiver 2026

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The document is a 'Written Notice of Withdrawal' form used by employees in Kentucky to retract a previous notice of rejection regarding workers' compensation coverage. It includes sections for employer and employee information, the effective date of withdrawal, and instructions for filing with the Department of Workers Claims. The form also outlines the conditions under which the withdrawal is effective and provides contact information for further inquiries.

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Click ‘Get Form’ to open the Kentucky Form 4 Waiver in our editor.
Begin by filling in the Employer Data section. Enter the Federal ID#, Employer Name, Phone Number, Street Address, City, State, ZIP, Nature of Business, and Number of Employees.
Next, complete the Employee Data section. Provide the Employee's Name, Social Security Number, Street Address, Phone Number, City, State, and ZIP.
In the body of the form, indicate your intention to withdraw the written notice of rejection by entering the effective date and the date when the rejection notice was filed.
Sign and date the form at the bottom where indicated for Employee Signature.
If required, have a Notary Public witness your signature and complete their section.
Finally, acknowledge receipt and filing by having an employer representative sign and date where indicated.

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Got questions?

We have answers to the most popular questions from our customers. If you can't find an answer to your question, please contact us.

Are you required to take a lunch break in Kentucky?

Federal law does not require lunch or coffee breaks.

Can I waive my lunch break in Kentucky?

What Not to Say to a Workers Comp Doctor Avoid Downplaying Your Injury: Dont minimize your pain or discomfort. Dont Speculate on Recovery Time: Do not make guesses about how quickly you will recover. Stay Away from Absolute Statements: Do not use words like always or never when describing your symptoms.

What is a workers comp waiver?

All waivers of subrogation for workers compensation insurance are prohibited in the commonwealth of Kentucky per KRS 342.700 (3).

What not to say to Workmans Comp?

Workers comp waivers can come from a client This is a standard legal protection that helps your clients manage their costs. Rather than paying for the cost of your coverage themselves, they make you pay for it. But in some contracts, youll find language that states you can waive your workers comp requirements.

kentucky form 4

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