FORM 10 Send original to
Workers' Compensation Court and 1 copy to Claimant or the Claimant's Attorney of Record In re claim of:
Full Name of Injured Employee (Claimant)
WORKERS' COMPENSATION COURT 1915 NORTH STILES OKLAHOMA CITY, OKLAHOMA 73105-4918
THIS SPACE FOR COURT USE ONLY
Claimant's Social Security Number
ANSWER AND PRETRIAL STIPULATION OFFERED BY RESPONDENT
Name of Employer (Respondent) Employer's Insurance Carrier, Permit # for Court Approved Individual Self-Insured or Own Risk Group, Uninsured
FILE NO. 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. Was claimant at the time of the alleged injury, an employee of the above named respondent? 2. Was claimant covered by the Workers' Compensation Act? 3. Did claimant sustain an accidental injury or suffer an occupational disease arising out of and in the course of the employment? 4. Has claimant filed a Form 3 within the statutory period of time? 5. Did respondent, at the time of the alleged injury, have an own-risk permit or a compensation insurance policy with the carrier named in the caption above? 6. Did claimant timely notify respondent of the injury? 7. Has claimant been provided medical treatment? 8. Has respondent commenced payment of temporary total disability payments to claimant? Temporary total disability has been paid to claimant from ________________________ to ___________________ for a total of _______________________ weeks in the total sum of $______________________________ .
9. Has respondent selected a treating physician? The treating physician is ___________________________________________________ (name of treating physician).
(ALL DEPOSITIONS OF MEDICAL EXPERTS SHALL BE COMPLETED PRIOR TO TRIAL)
________ ________ 10. Is rate an issue? Claimant's compensation rate: TTD __________________ PPD ________________. 11. State all affirmative defenses: _______________________________________________________________________________________________ ________________________________________________________________________________________________________________________ 12. List the names of all witnesses who may be called by respondent at trial: ____________________________________________________________ ________________________________________________________________________________________________________________________ 13. List all exhibits to be introduced at trial: ________________________________________________________________________________________ 14. Respondent hereby certifies that a copy of the medical report written by Dr. ___________________________________ and dated _______________, was mailed, together with a copy of this motion to Opposing party/Counsel.
(LIST ON A SEPARATE SHEET, ADDITIONAL WITNESSES, EXHIBITS AND MEDICAL EVIDENCE)
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 COPY HAS BEEN SENT TO: Opposing Party Address (Number & Street) City State Zip Code
Signed this________________day of______________________,___________.
Signature of Filing Party Address (Number & Street) City Telephone # of Filing Party Print or type name of Attorney OBA # State Zip Code