Send original to Workers' Compensation Court and 1 copy to All Other Parties of Record In re claim of:
Full Name of Claimant (Injured Employee)
THIS SPACE FOR COURT USE ONLY
WORKERS COMPENSATION COURT 1915 NORTH STILES OKLAHOMA CITY, OKLAHOMA 73105-4918
Claimant's Social Security Number
Name of Employer or Respondent
REQUEST FOR PREHEARING CONFERENCE FILE NO.
Date of Injury
Employer's Insurance Carrier, Permit # for Court Approved Individual Self-Insured or Own Risk Group, Uninsured
(Please type or print) NOTE: Mediation is available to address certain workers' compensation disputes. (800) 522-8210. For information, call (405) 522-8760 or in-state toll free
Movant respectfully requests that the captioned cause be set for Prehearing Conference at the earliest possible date to address the following issue(s): a. Motion to terminate temporary compensation. b. Objection to Termination of Temporary Compensation based on: 85 O.S. Section 14(A)(2) Court Appointed IME Treating Physician Other _______________________________________ (Specify)
c. Motion to appoint an Independent Medical Examiner per 85 O.S., Section 17. d. Motion to appoint an Independent Medical Examiner per 85 O.S., Section 201.1(B)(5) for pre-authorization for treatment. e. Motion to Consolidate. LIST ALL COURT FILE NUMBERS, EXCLUDING THE ONE LISTED ABOVE. ____________ f ____________ ____________ ____________ Motion to Hold in Abeyance. and INSURER, and the alleged DATE OF INJURY. (Use additional sheets if necessary.) A COPY OF THIS MOTION MUST BE MAILED TO EACH ADDITIONAL PARTY AND INSURER LISTED.
Additional Party & Address, including City/State/Zip Insurer & Address, including City/State/Zip Alleged Date of Injury
g. Motion to Join Additional Parties. Include the name and complete address, including the zip code, of EACH additional party
____________________________________ | __________________________________________ | _____________________
h. Settlement conference before a judge other than the assigned trial judge. i. 2. 3. Mediation Order. (Note: Contact the Counselor Department directly to pursue mediation by mutual agreement without Court order.) j. Other __________________________________________________________________________________________ (specify). Has a trial judge previously been assigned by the Court to hear all matters relating to the above-captioned cause of action? YES NO ASSIGNED TRIAL JUDGE: ___________________________________. Oklahoma City Tulsa Other _____________________ (specify). The agreed venue for this Prehearing Conference is:
THE PARTY MAKING THIS REQUEST FOR A PREHEARING CONFERENCE HEREBY CERTIFIES THAT THE PARTIES HAVE DISCUSSED THE ISSUE TO BE PRESENTED TO THE COURT AND CANNOT, IN GOOD FAITH, REACH A RESOLUTION OF THE ISSUE WITHOUT THE COURT'S ASSISTANCE. 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/Counsel Address (Number and Street) City State Zip Code
Signed this ____________day of _________________, __________.
Signature of Requesting Party Address City State Zip Code
Telephone Number of Requesting Party Print or type name of Attorney OBA #