Free Form 3F.pub - Oklahoma



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FORM 3F Send original to Workers' Compensation Court and 1 copy to Multiple Injury Trust Fund WORKERS' COMPENSATION COURT 1915 NORTH STILES OKLAHOMA CITY, OK 73105-4918 Please check appropriate box I. Original Filing II. Amends Previously Filed Form 3F (Must clearly state whether amendment is in addition to, or substitute for, prior information.) THIS SPACE FOR COURT USE ONLY Name of Claimant (injured employee) MULTIPLE INJURY TRUST FUND P.O. Box 528801 Oklahoma City, OK 73152 (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 Social Security # EMPLOYEE'S CLAIM FOR BENEFITS FROM THE MULTIPLE INJURY TRUST FUND FILE NO. Phone: ( Date of Birth: Date of Order ) Age: Sex: Percentage of Dis

FORM 3F
Send original to Workers' Compensation Court and 1 copy to Multiple Injury Trust Fund

WORKERS' COMPENSATION COURT 1915 NORTH STILES OKLAHOMA CITY, OK 73105-4918
Please check appropriate box
I. Original Filing II. Amends Previously Filed Form 3F (Must clearly state whether amendment is in addition to, or substitute for, prior information.)

THIS SPACE FOR COURT USE ONLY

Name of Claimant (injured employee)

MULTIPLE INJURY TRUST FUND P.O. Box 528801 Oklahoma City, OK 73152 (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 Social Security #

EMPLOYEE'S CLAIM FOR BENEFITS FROM THE MULTIPLE INJURY TRUST FUND
FILE NO.

Phone: ( Date of Birth: Date of Order

) 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

P R I O R

Amount of JP or Other Settlement

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 MULTIPLE INJURY TRUST FUND on the _________________ day of ____________________, _______ Name of claimant's attorney if represented: Type or Print Name of Attorney: Mailing Address: City: Telephone #: ( ) State: Zip: Signed this __________day of______________________,______________ OBA # Upon filing this Claim For Benefits from the Multiple Injury Trust Fund, permission is given to the Administrator of the Workers' Compensation Court, the Insurance Commissioner, the Attorney General, a district attorney of their designees to examine all records relating to the claim. The permission granted to the above named individuals or their designees authorizes them to access 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.

____________________________________________________________ 2/06 Signature of Attorney for Claimant

____________________________________________________________ Signature of Claimant (must be signed by claimant)

File Size: 47.8 kB
Pages: 1
Date: February 13, 2006
File Format: PDF
State: Oklahoma
Category: Workers Compensation
Author: CHiggins
Word Count: 454 Words, 3,079 Characters
Page Size: Letter (8 1/2" x 11")
URL

http://www.owcc.state.ok.us/CourtForms/Current/Form%203F.pdf