Send original to Workers' Compensation Court and 1 copy to Each Opposing Party/Counsel In re claim of:
Full Name of Claimant (Injured Employee)
WORKERS' COMPENSATION COURT 1915 NORTH STILES OKLAHOMA CITY, OKLAHOMA 73105-4918
THIS SPACE FOR COURT USE ONLY
Claimant's Social Security Number
Name of Employer (Respondent) Employer's Insurance Carrier, Permit # for Court Approved Individual Self-Insured or Own Risk Group, Uninsured
MOTION TO SET FOR TRIAL
File Number Date of Injury
NOTE: Mediation is available to address certain workers' compensation disputes. For information, call (405) 522-8760 or in-state toll free (800) 522-8210.
(Please Type or Print) 1. Issues to be tried: (Circle all applicable issues below.) a. b. c. d. e. f. g. h. i. j. k. l. n. 2. 3. 4. Temporary Total Disability from ________________________ to _______________________________. Medical Treatment from _____________________________ to ________________________________. Permanent Partial Disability. Permanent Total Disability. Motion to Reopen on Change of Condition. Has the Reopen Fee been paid? YES NO Change of Physician for a worker covered by a Certified Workplace Medical Plan (CWMP). (Note: File a Form A to set a request for Change of Physician when there is no CWMP.) Change of Case Manager for a worker not covered by Certified Workplace Medical Plan (CWMP). Liability of Multiple Injury Trust Fund. Liability of Last Employer for Combined Disabilities. Rate: TTD____________________PPD____________________AWW_________________. Death Benefits. Appeal from Form 18 Order. YES NO Other (SPECIFY)_____________________________________________________________________________________. (ALL DEPOSITIONS OF MEDICAL EXPERTS SHALL BE COMPLETED PRIOR TO TRIAL.) List the names of all witnesses who may be called at trial:________________________________________________________________ ______________________________________________________________________________________________________________ List all exhibits to be introduced at trial: ______________________________________________________________________________ ______________________________________________________________________________________________________________ Requestor hereby certifies that a copy of the medical report written by Dr. _______________________and dated ________________ was mailed, together with this motion, to Opposing Party/Counsel. (Refer to Court rules regarding the exchange of exhibits.) Do NOT attach a copy of the medical report when filing the Form 9 with the Workers' Compensation Court. The agreed venue for this trial is: Oklahoma City Tulsa Other_________________________ (specify).
m. Form 19 (Request For Payment of Health or Rehabilitation Services). Was the Form 19 filed previously?
I declare under penalty of perjury that I have examined this motion 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. I HEREBY CERTIFY THAT A COPY HAS BEEN SENT TO: Opposing Party/Counsel Address (Number & Street) City State Zip Code
Signed this________________day of______________________,___________.
Signature of Requesting Party Address (Number & Street) City State Zip Code claimant resp. med/rehab provider
Telephone # of Requesting Party Print or type name of Attorney