Send original and 4 copies to Workers' Compensation Court
WORKERS' COMPENSATION COURT 1915 NORTH STILES OKLAHOMA CITY, OK 73105-4918
Please check appropriate box
I. Original Filing II. Amends Previously Filed Form 3A (Must clearly state whether amendment is in addition to, or substitute for, prior information.)
THIS SPACE FOR COURT USE ONLY
IN THE MATTER OF THE DEATH OF (deceased employee) Name of Claimant (individual filing claim) Name of Employer Court Use Only
CLAIMANT'S FIRST NOTICE OF DEATH 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.
Social Security #: Date of Birth: Was deceased employment agreement made in Oklahoma? YES NO Phone: ( ) Age: Average Weekly Wage: Phone: ( Sex:
DECEASED EMPLOYEE NAME (Last, First, Middle): Mailing Address (include City, State & Zip): Occupation: Claimant's Name (Last, First, Middle): Mailing Address (include City, State & Zip): Date of Accidental Injury Date of Death Nature of Injury Time: ______________ AM Time: ______________ AM
Relationship to Deceased Place of Injury: PM Place of Death: PM Body part(s) injured City/County/State City/County/State
Describe activities when injury occurred, with details of how event occurred. Include object or substance which directly injured deceased. Cause of death (normally shown on Death Certificate) Employer: Complete Mailing &/or Street Address: Has a personal representative been appointed for the estate of the deceased? Has deceased filed a claim for compensation regarding this accident? YES NO Federal ID# City: YES NO Telephone: State: Zip:
If so, state the name and address below.
________________________________________________________________________________________________________________________________ List names, relationships, addresses and dates of birth of all heirs at law of deceased and any other person who actually depended upon deceased at the time of death. (on the reverse side) 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 Death 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 Attorney for Claimant 2/06
Signature of Claimant (must be signed by claimant)