Send original and 4 copies to: Workers' Compensation Court Name of Claimant (Injured Employee) Name of Employer Court Use Only
WORKERS' COMPENSATION COURT 1915 NORTH STILES OKLAHOMA CITY, OK 73105-4918
Please check appropriate box
I. Original Filing II. Amends Previously Filed Form 3 (Must clearly state whether amendment is in addition to, or substitute for, prior information.)
THIS SPACE FOR COURT USE ONLY
EMPLOYEE'S FIRST NOTICE OF ACCIDENTAL INJURY AND CLAIM FOR COMPENSATION
(Please type or print)
NOTE: Mediation is available to address certain workers' compensation disputes. For information, call (405) 522-8760 or in-state toll free (800) 522-8210.
Phone: Social Security #: EMPLOYEE NAME (Last, First, Middle): ) NOTE: A voluntary Mediation Program to address certain workers' compensation disputes is available through( the Workers' Compensation Court. For information, call (405) State & Zip):or (800) 522-8210. Sex: Mailing Address (include City, 522-8760 Date of Birth: Age: Occupation: Date of Accident or Last Exposure: Describe parts of the body injured or affected What is the nature of the Injury or Illness: Treating Physician (full name): Employer: Complete Mailing Address: Complete Street Address (if different from above): Was your employment agreement in Oklahoma? YES NO Injury resulted from: Single Incident Avg. Weekly Wage: Length of Employment years _____________ months _________ Time Injury Occurred __________________ AM PM
Place of Injury: City/County/State Describe with details how the injury occurred. Include object or substance which directly injured you: Address: City: Employer's FEI # (Federal ID Number): City: City: State: Zip:
Telephone: State: State: Zip: Zip:
Are you a previously impaired person due to a prior workers' compensation injury or obvious and apparent pre-existing disability? _______ If "YES", you may be entitled to benefits for combined disabilities. Any claim made for benefits for combined disabilities must be commenced by filing a "Form 3E" or "Form 3F", as appropriate, with the Workers' Compensation Court. 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 declare under penalty of perjury that I have examined this notice and claim, 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. Name of claimant's attorney if represented: Type or Print Name of Attorney: Mailing Address: City Telephone #: ( ) State Zip OBA# Upon filing this Notice of Accidental Injury And Claim For Compensation, 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. The permission granted to the above named individuals or their designees authorizes them access to medical records pursuant to Section 19 of Title 76 of the Oklahoma Statutes, including waiver of any privilege granted by law concerning communications made to a physician or health care provider or knowledge obtained by such physician or health care provider by personal examination. Signed this _______________ day of ________________________ , ________
Signature of Claimant (must be signed by claimant) Signature of Attorney for Claimant 2/06 This form is not intended for use as a medical authorization. Nothing shall be construed to waive, limit or impair any evidentiary privilege recognized by law.