Free Form 2.pub - Oklahoma

FORM 2 Send original to
Workers' Compensation Court and 1 copy to Insurance Carrier
Please type or print. Enter all dates in MM/DD/YY format.
Full Name of Employee - LAST, FIRST, MIDDLE

WORKERS' COMPENSATION COURT 1915 NORTH STILES OKLAHOMA CITY, OK 73105-4918

EMPLOYER'S FIRST NOTICE OF INJURY
THIS SPACE FOR COURT USE ONLY

Complete Address

City

State

Zip

Telephone Number

Social Security Number

Date of Birth

Sex

Length of Employment Years Months Was employment agreement made in Oklahoma? YES NO

Average Weekly Wage

Occupation (job description)

NOTE: Mediation is available to address certain workers' compensation disputes. (800) 522-8210.
Date of accident or last exposure Time of accident or exposure o'clock Last date employee worked Has employee returned to work? YES OSHA Log Case # NO If yes, on what date Place of Accident or Occurrence City: Injury Resulted from: Single Incident Cumulative Trauma AM PM

For information, call (405) 522-8760 or in-state toll free
Time workday began o'clock AM PM

Date Employer Notified

Did the employee die? YES NO If yes, on what date

County: Does employee participate in a certified workplace medical plan: YES

State: NO

If yes, name of CWMP: __________________________________________________________________ Nature of Injury or Illness

Describe activities when injury occurred with details of how event occurred. Include object or substance which directly injured the employee.

Identify part(s) of body involved in injury or illness

Full Name and address of Treating Physician (please be complete)

Employer's Insurance Carrier or Own Risk Group Name Address Employer's Name and Complete Address Name Address Type of business (Example: manufacturing, food service, construction) Federal ID# City Phone City

Policy/Self-Insured Number Policy Period--from State Zip to

Phone # State Zip SIC Number

Type of Ownership:

Private

State Government

County Government

Local Government

Upon filing this Notice of Injury, permission is given to the Administrator of the Workers' Compensation Court, the Insurance Commissioner, the Attorney General, a District Attorney or their designees to examine all records relating to the notice, any matter contained in the notice, and any matter relating to the notice. Any person receiving temporary disability benefits from an employer or the employer's insurance carrier shall promptly report in writing to the employer or insurance carrier any change in a material fact or the amount of income the employee is receiving or any change in the employee's employment status, occurring during the period of receipt of such benefits. I hereby declare under penalty of perjury that I have examined this notice, and all statements contained herein, and to the best of my knowledge and belief, they are true, correct and complete. Any person who commits workers' compensation fraud, upon conviction, shall be guilty of a felony.

Signed this Prepared by Title

day

,

I hereby certify that this Form 2 was sent to the Workers' Compensation Court and a copy thereof to the insurer on the date described below:

,
SUBMISSION OF THIS FORM IS NOT AN ADMISSION OF LIABILITY

A Form 2 must be sent to the Workers' Compensation Court and to the Employer's Workers' Compensation Insurance Carrier within 10 days, or a reasonable time thereafter, of learning that an employee has suffered an accidental injury which results in lost time beyond the shift, or requires medical attention away from the work site, fatal or otherwise. Form 2s filed with the Workers' Compensation Court are confidential and not subject to public disclosure except as authorized by law. 2/06