Free Form 1A - English rev - Oklahoma

File Size: 45.9 kB
Pages: 1
File Format: PDF
State: Oklahoma
Category: Workers Compensation
Author: JLutter
Word Count: 876 Words, 5,462 Characters
Page Size: Letter (8 1/2" x 11")

Download Form 1A - English rev ( 45.9 kB)

Preview Form 1A - English rev
Form 1A

Oklahoma Workers' Compensation Notice and Instruction to Employers and Employees

All employees of this employer who are entitled to benefits of the Workers' Compensation Act are hereby notified that this employer has complied with all rules of the Workers' Compensation Court and that this employer has secured payment of compensation for all employees and their dependents in accordance with the Act. All employees are further notified this employer will furnish first aid, medical, surgical and any other like services required by law as well as payments of compensation to any injured employee as provided in the Workers' Compensation Act. Any employee who has suffered a compensable injury covered by the Workers' Compensation Act shall be entitled to vocational rehabilitation services, including retraining and job placement, if, as a result of the injury, the employee is unable to perform the same occupational duties the employee was performing prior to the injury. NOTE: Mediation is available to address certain workers' compensation disputes. For information, call (405) 522-8760 or instate toll free (800) 522-8210. The Oklahoma Workers' Compensation Court has a counselor program to provide information to injured workers, employers, and other interested parties. Counselors assist unrepresented parties to enable them to protect their rights under the workers' compensation system.

Signature of Employer

Insurer & Insurer Phone Number

Employee's Responsibilities in Case of Accidental Injury or Occupational Disease
If accidentally injured or affected by an occupational disease arising out of and in the course of employment, however slight, the employee should notify the employer immediately. If this employer is a partnership, notice shall be given to any partner. If this employer is a corporation, notice shall be given to any agent or officer of the corporation upon whom legal process may be served. Notice shall also be given to the person in charge of business at the location of operations where the injury occurred. Unless notice is given to the employer or medical treatment is rendered within thirty (30) days of injury, any claim for compensation may be forever barred. If accidentally injured or affected by an occupational disease, the employee may file a claim for compensation with the Workers' Compensation Court. This employer is required to furnish the employee with appropriate forms to file a compensation claim. A claim for compensation must be filed with the court within a period of time specified by statute, or be forever barred. Based on statute effective July 1, 2005, if a claim for compensation for any accidental injury or death is not filed with the Court within two (2) years from the date of the accidental injury or death or if a claim for compensation for occupational disease or cumulative trauma is not filed within two (2) years of either the last hazardous exposure or from the date the disease first became manifest, which ever last occurred, the claim for compensation may be forever barred. Provided, claims may be filed within two (2) years from the date of the last medical treatment authorized by the employer or payment of any compensation or remuneration paid in lieu of compensation. Post termination claims must be filed within six (6) months of termination of employment. 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.

Employer's Responsibilities
The employer must provide employees with immediate first aid, medical and surgical care and other like services necessary. This applies to care for all injuries and illnesses arising out of and in the course of employment, regardless of their character. If an employee is injured and this results in the loss of time beyond his/her shift, or requires medical attention away from the work site (fatal or otherwise), the employer MUST file a Form 2 within ten (10) days of the notice of injury or a reasonable time thereafter. The employer must provide a copy of such Form 2 to the employer's workers' compensation insurance carrier, if any. No agreement by any employee to pay any portion of premiums paid by the employer to maintain or carry compensation insurance as required by law shall be valid. Any employer who deducts money from the wages or salary of any employee for that purpose who is entitled to workers' compensation shall be guilty of a misdemeanor. If the employer has notice of an undisputed injury and the employer's insurance carrier fails to commence weekly temporary total disability benefit payments due within the time provided by law, the insurer may be subject to a penalty of fifteen percent (15%) of the unpaid or delayed weekly benefits due and payable to the employee. No agreement by any employee to waive workers' compensation rights and benefits shall be valid. Any person who commits workers' compensation fraud, upon conviction, shall be guilty of a felony.

Workers' Compensation Court
1915 North Stiles Avenue Oklahoma City, Oklahoma 73105-4918 (405) 522-8600 WATS # 1-800-522-8210 07/05 This notice must be posted and maintained by the employer in one or more conspicuous places.