Free Form - Oklahoma

File Size: 74.3 kB
Pages: 1
Date: April 12, 2006
File Format: PDF
State: Oklahoma
Category: Workers Compensation
Author: JLutter
Word Count: 574 Words, 3,842 Characters
Page Size: Letter (8 1/2" x 11")

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Send original and 4 copies to: Workers' Compensation Court


Please check appropriate box
I. Original Filing


Name of Claimant (Injured Employee) Name of Employer

II. Amends Previously Filed Form 3B (Must clearly state whether amendment is in addition to, or substitute for, prior information.) EMPLOYEE'S FIRST NOTICE OF OCCUPATIONAL DISEASE AND CLAIM FOR COMPENSATION

Court use only NOTE: Mediation is available to address certain workers' compensation disputes. (800) 522-8210.


For information, call (405) 522-8760 or in-state toll free

(Please type or print)
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. 522-8760 Sex: Mailing Address (include City, Date of Birth: Age: Occupation: Was your employment agreement in Oklahoma? YES NO Avg. Weekly Wage: Length of Employment months_____________ years_________

Date of last exposure to hazard which caused Date of first distinct manifestation: disease: Nature of Disease (example: Reduced breathing capacity or loss of vision)

Place of Injury: City/County/State Body Part(s) Injured:

Describe how you were exposed to the disease with details of how event occurred. Include object or substance which directly injured you: Employer: Complete Mailing Address: Complete Street Address (if different from above): Employer's FEI # (Federal ID Number): City: City: 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 Occupational Disease 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 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. 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 Signed this _______________ day of ________________________ , ________


Signature of Attorney for Claimant

Signature of Claimant (must be signed by claimant)