Send original to Workers' Compensation Court and 1 copy to Opposing Party/Counsel
Name of Claimant (Injured employee) Name of Employer
WORKERS' COMPENSATION COURT 1915 NORTH STILES OKLAHOMA CITY, OK 73105-4918
Please check appropriate box
I. Original Filing II. Amends Previously Filed Form 3E (Must clearly state whether amendment is in addition to, or substitute for, prior information.)
THIS SPACE FOR COURT USE ONLY
Employer's Insurance Carrier, Permit # for Court Approved Individual Self-Insured or Own Risk Group, Uninsured
NOTE: Mediation is available to address certain workers' compensation disputes. For information, call (405) 522-8760 or in-state toll free (800) 522-8210.
EMPLOYEE'S CLAIM FOR BENEFITS FOR COMBINED DISABILITIES AGAINST THE LAST EMPLOYER
(Please type or print) EMPLOYEE NAME (Last, First, Middle) Mailing Address (include City, State & Zip) Court File Number for most recent injury Amount of Joint Petition or Other Settlement Date of Injury Date of Order Social Security # Date of Birth Phone: ( ) Age: Sex:
Percentage of Disability Awarded and Body Part
Rate of weekly compensation for permanent partial disability at the time of the most recent injury
Court File No.
Date of Injury
Date of Order
% of Disability & body Part
Amount of JP or Other Settlement
P R I O R
Are weekly benefits still being paid on any of the above orders? _________________ YES ___________________ NO If so, when are benefits expected to terminate? _____________________________________________________________ List and describe fully any other pre-existing disability for which no award has been made. (Pre-existing disability means any obvious and apparent disability resulting from any cause, which disability is obvious and apparent from observation of a person who is not skilled in the medical profession.)
I declare under penalty of perjury that I have examined 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. I hereby certify that a true and correct copy of this claim was mailed to the above named employer or its counsel on the _____________day of ___________,_______. Name of claimant's attorney if represented: Type or Print Name of Attorney: Mailing Address: City Telephone #: ( ) State Zip OBA # Upon filing this Claim For Benefits for Combined Disabilities Against the Last Employer, 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 claim. 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 01/06
Signature of Claimant (must be signed by claimant)