Free Form 7 - Oklahoma



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FORM 7 Send original to Workers' Compensation Court WORKERS' COMPENSATION COURT 1915 NORTH STILES OKLAHOMA CITY, OK 73105-4918 This space for Court Use only Designation of Service Agent Pursuant to Workers' Compensation Court Rule 10: When the claimant files a claim for compensation (Form 3, Form 3A or Form 3B), the Court shall mail a file-stamped copy of the claim form bearing the assigned file number to a single service agent of the self-insured employer, group self-insurance association, insurance carrier or CompSource Oklahoma which shall be designated on a Form 7 and filed with the Court. The Court shall send all notices and correspondence to the service agent until an entry of appearance or notice of substitution of attorney is filed pursuant to Rule 7. If no service agent is designated on the Form 7, notices and correspondence shall

FORM 7 Send original to
Workers' Compensation Court

WORKERS' COMPENSATION COURT 1915 NORTH STILES OKLAHOMA CITY, OK 73105-4918

This space for Court Use only

Designation of Service Agent
Pursuant to Workers' Compensation Court Rule 10: When the claimant files a claim for compensation (Form 3, Form 3A or Form 3B), the Court shall mail a file-stamped copy of the claim form bearing the assigned file number to a single service agent of the self-insured employer, group self-insurance association, insurance carrier or CompSource Oklahoma which shall be designated on a Form 7 and filed with the Court. The Court shall send all notices and correspondence to the service agent until an entry of appearance or notice of substitution of attorney is filed pursuant to Rule 7. If no service agent is designated on the Form 7, notices and correspondence shall be sent to: 1. 2. 3. 4. 5. The signatory on the self-insurance application, if the insurer is a self-insured employer; The Administrator of the group self-insurance association, if the insurer is a group self-insurance association; The person designated to receive notice of service of process for an insurer as provided in 36 O.S., Section 621, if the insurer is a foreign or alien insurance carrier; The President and Chief Executive Officer of CompSource Oklahoma, if the insurer is CompSource Oklahoma; or The service agent on file with the Secretary of State, if the insurer is a domestic insurance carrier.

If the employer is uninsured or the Court cannot determine insurance coverage, notices and correspondence shall be sent by certified mail to the employer's last known address. The following information is required and must be amended whenever a change of service agent is made. Please check ( ) the appropriate box below

Name of:

Carrier

Self-Insured Employer

Group Self-Insurance Association

Home office mailing address:

City

State

Zip

Street Address, if different from mailing address:

Phone Number

Designated Service Agent

Name of Individual or Business:

Name of contact person, if the service agent is a business:

Mailing address:

City

State

Zip

Street Address, if different from mailing address:

Phone Number

Signed this ____________ day of __________________, __________ Signature I HEREBY CERTIFY THAT THIS DOCUMENT WAS MAILED TO THE WORKERS' COMPENSATION COURT ON: _____________________________________, _______________
2/06

Prepared by _______________________________________________ Title _____________________________________________________

File Size: 39.1 kB
Pages: 1
Date: February 13, 2006
File Format: PDF
State: Oklahoma
Category: Workers Compensation
Author: BCDelozier
Word Count: 365 Words, 2,544 Characters
Page Size: Letter (8 1/2" x 11")
URL

http://www.owcc.state.ok.us/CourtForms/Current/Form%207.pdf