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Technical Amendment: 10/27/2022

EDUCATION AND LABOR CABINET

(Technical Amendment)

803 KAR 25:130.Notice of Rejection of Workers' Compensation Act.

RELATES TO:

KRS 342.395

STATUTORY AUTHORITY:

KRS 342.260(1)

CERTIFICATION STATEMENT:

NECESSITY, FUNCTION, AND CONFORMITY:

KRS 342.260(1) requires the commissioner~~executive director~~ to promulgate administrative regulations necessary to carry out the work of the department~~office~~. KRS 342.395 requires an employer to file an employee's notice of rejection of workers' compensation with the department~~office~~. This administrative regulation establishes the procedures for filing the rejection notice, the form of the rejection notice, and the withdrawal of the rejection notice.

Section 1. (1)

If an employee chooses to reject the provisions of KRS Chapter 342, the employee shall file a Form No. 4, Employee's Notice of Rejection of Workers' Compensation Act with his employer.

(2)

The notice shall:

(a)

Be on an original form obtained from the Department~~Office~~ of Workers' Claims;

(b)

Contain the following information:

1.

Employer data;

2.

Employee data;

3.

Employer's Workers' Compensation Insurance data;

4.

Employee's notarized signature; and

5.

Employer's acknowledgment of receipt and filing with the Department~~Office~~ of Workers' Claims; and

(c)

Be effective when the department~~office~~ has received the fully completed Form No. 4.

(3)

The employer shall file each Form No. 4 with the department~~office~~ immediately upon receipt of the form from the employee.

(4)

Each employer shall:

(a)

Keep on file a copy of each Form No. 4 signed by a current employee; and

(b)

Make those records available for inspection upon request by a representative of the department~~office~~.

(5)

The department~~office~~ shall reject a filing which is:

(a)

A photocopy;

(b)

A facsimile;

(c)

Not on an original Form No. 4 obtained from the department~~office~~.

Section 2. (1)

If an employee chooses to withdraw his rejection of the Workers' Compensation Act, the employee shall file that withdrawal on Form No. 5, Written Notice of Withdrawal of Form No. 4 Rejection Notice with his employer.

(2)

The withdrawal notice shall:

(a)

Be on an original form obtained from the department~~office~~;

(b)

Contain the following information:

1.

Employer data;

2.

Employee data;

3.

Employee's notarized signature;

4.

Employer's acknowledgment of receipt and filing with the department~~office~~; and

5.

Pursuant to KRS 342.395(3), the date when the withdrawal is to become effective; and

(c)

Be effective pursuant to KRS 342.395(3) upon:

1.

Filing with the employer, if the employee did not designate an effective date; or

2.

The date designated by the employee.

(3)

The employer shall file each Form No. 5 with the department~~office~~ immediately upon receipt from the employee.

Section 3.

If an employer or employee wants an acknowledgment from the department~~office~~ of a Form No. 4 filing or Form No. 5 filing, the employer or employee shall provide the following with the original Form No. 4 or Form No. 5:

(1)

Photostatic copy of the filing; and

(2)

Self-addressed stamped envelope.

Section 4.

Incorporation by Reference.

(1)

The following material is incorporated by reference:

(a)

Form No. 4, Employee's Notice of Rejection of Workers' Compensation Act (July 1997 Edition), Office of Workers' Claims; and

(b)

Form No. 5, Written Notice of Withdrawal of Form 4 Rejection (July 1997 Edition), Office of Workers' Claims.

(2)

The material may be inspected, copied or obtained at the Department~~Office~~ of Workers' Claims, Monday through Friday, 9 a.m. to 4 p.m. at Prevention Park, 657 To Be Announced Avenue, Frankfort, Kentucky 40601.

HISTORY: (803 KAR 025:130. 24 Ky.R. 1187; 1518; eff. 1-12-1998; TAm eff. 8-9-2007; Crt eff. 3-29-2019; TAm eff. 10-31-2022; Crt to Am 3-5-2026; Recodified to 120 KAR 001:130; eff. 6-29-2026.)

Technical Amendment: 10/27/2022

EDUCATION AND LABOR CABINET

(Technical Amendment)

803 KAR 25:130.Notice of Rejection of Workers' Compensation Act.

RELATES TO:

KRS 342.395

STATUTORY AUTHORITY:

KRS 342.260(1)

CERTIFICATION STATEMENT:

NECESSITY, FUNCTION, AND CONFORMITY:

KRS 342.260(1) requires the commissioner to promulgate administrative regulations necessary to carry out the work of the department. KRS 342.395 requires an employer to file an employee's notice of rejection of workers' compensation with the department. This administrative regulation establishes the procedures for filing the rejection notice, the form of the rejection notice, and the withdrawal of the rejection notice.

Section 1. (1)

If an employee chooses to reject the provisions of KRS Chapter 342, the employee shall file a Form No. 4, Employee's Notice of Rejection of Workers' Compensation Act with his employer.

(2)

The notice shall:

(a)

Be on an original form obtained from the Department of Workers' Claims;

(b)

Contain the following information:

1.

Employer data;

2.

Employee data;

3.

Employer's Workers' Compensation Insurance data;

4.

Employee's notarized signature; and

5.

Employer's acknowledgment of receipt and filing with the Department of Workers' Claims; and

(c)

Be effective when the department has received the fully completed Form No. 4.

(3)

The employer shall file each Form No. 4 with the department immediately upon receipt of the form from the employee.

(4)

Each employer shall:

(a)

Keep on file a copy of each Form No. 4 signed by a current employee; and

(b)

Make those records available for inspection upon request by a representative of the department.

(5)

The department shall reject a filing which is:

(a)

A photocopy;

(b)

A facsimile;

(c)

Not on an original Form No. 4 obtained from the department.

Section 2. (1)

(2)

The withdrawal notice shall:

(a)

Be on an original form obtained from the department;

(b)

Contain the following information:

1.

Employer data;

2.

Employee data;

3.

Employee's notarized signature;

4.

Employer's acknowledgment of receipt and filing with the department; and

5.

Pursuant to KRS 342.395(3), the date when the withdrawal is to become effective; and

(c)

Be effective pursuant to KRS 342.395(3) upon:

1.

Filing with the employer, if the employee did not designate an effective date; or

2.

The date designated by the employee.

(3)

The employer shall file each Form No. 5 with the department immediately upon receipt from the employee.

Section 3.

If an employer or employee wants an acknowledgment from the department of a Form No. 4 filing or Form No. 5 filing, the employer or employee shall provide the following with the original Form No. 4 or Form No. 5:

(1)

Photostatic copy of the filing; and

(2)

Self-addressed stamped envelope.

Section 4.

Incorporation by Reference.

(1)

The following material is incorporated by reference:

(a)

Form No. 4, Employee's Notice of Rejection of Workers' Compensation Act (July 1997 Edition), Office of Workers' Claims; and

(b)

Form No. 5, Written Notice of Withdrawal of Form 4 Rejection (July 1997 Edition), Office of Workers' Claims.

(2)

The material may be inspected, copied or obtained at the Department of Workers' Claims, Monday through Friday, 9 a.m. to 4 p.m. at Prevention Park, 657 To Be Announced Avenue, Frankfort, Kentucky 40601.

HISTORY: (803 KAR 025:130. 24 Ky.R. 1187; 1518; eff. 1-12-1998; TAm eff. 8-9-2007; Crt eff. 3-29-2019; TAm eff. 10-31-2022; Crt to Am 3-5-2026; Recodified to 120 KAR 001:130; eff. 6-29-2026.)

Page Generated: 7/23/2026, 4:32:14 PM

Title 803 | Chapter 025 | Regulation 130

803 KAR 25:130.Notice of Rejection of Workers' Compensation Act.

RELATES TO:

STATUTORY AUTHORITY:

CERTIFICATION STATEMENT:

NECESSITY, FUNCTION, AND CONFORMITY:

Section 1.

(1)

(2)

(a)

(b)

1.

2.

3.

4.

5.

(c)

(3)

(4)

(a)

(b)

(5)

(a)

(b)

(c)

Section 2.

(1)

(2)

(a)

(b)

1.

2.

3.

4.

5.

(c)

1.

2.

(3)

Section 3.

(1)

(2)

Section 4.

(1)

(a)

(b)

(2)

803 KAR 25:130.Notice of Rejection of Workers' Compensation Act.

RELATES TO:

STATUTORY AUTHORITY:

CERTIFICATION STATEMENT:

NECESSITY, FUNCTION, AND CONFORMITY:

Section 1.

(1)

(2)

(a)

(b)

1.

2.

3.

4.

5.

(c)

(3)

(4)

(a)

(b)

(5)

(a)

(b)

(c)

Section 2.

(1)

(2)

(a)

(b)

1.

2.

3.

4.