Free Form 20.pub - Oklahoma

Send original to Workers' Compensation Court and 1 copy to All Other Parties of Record

FORM 20

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

THIS SPACE FOR COURT USE ONLY

IN THE MATTER OF THE DEATH OF
Name of deceased employee Name of person filing Proof of Loss Name of Employer or Respondent Employer's Insurance Carrier, Permit # for Court Approved Individual Self-Insured or Own Risk Group, Uninsured

PROOF OF LOSS FOR SPOUSE AND CHILDREN (Lump Sum Benefits)

FILE NO.
Deceased Employee's Social Security Number

STATE OF OKLAHOMA

) ) COUNTY OF __________________________)

SS.

(PLEASE TYPE OR PRINT)

______________________________________________, of lawful age, being first duly sworn on oath, alleges and states:
(relation to decedent) That affiant is the _______________________________________ and ________________________________________ (relation to children) That on the ___________ day of _______________, _________ , the decedent, _____________________________________

sustained an accidental personal injury arising out of and while in the course of employment and died as a result of said injuries on the __________ day of _________________, __________. Affiant states that at the time of death, decedent was lawfully married to ____________________________________________ residing at ____________________________________________, and left surviving the following named children: NAME (List additional children on back of form) DATE OF BIRTH _____________ _____________ _____________ ADDRESS ___________________________________ ___________________________________ ___________________________________

1. ___________________________________________ 2. ___________________________________________ 3. ___________________________________________

4. ___________________________________________ _____________ ___________________________________ Affiant further declares under penalty of perjury that affiant has examined this proof of loss and the statements contained herein, and to affiant's best knowledge and belief they are true, correct and complete. Any person who commits workers' compensation fraud, upon conviction, shall be guilty of a felony. Affiant hereby certifies that copies of necessary marriage, birth and death certificates were mailed to the opposing party/counsel on ____________________. NOTE: Certified copies of these documents shall be offered at the time of trial. Signed this________________day of___________,______
____________________________________________________________ Signature of person completing the Proof of Loss I HEREBY CERTIFY THAT A COPY HAS BEEN SENT TO: Opposing Party Address (Number and Street) City State Zip Code Name of claimant's attorney, if represented Address of Attorney City Telephone # State Zip Code OBA #

2/06

_____________________________________________________
Signature of Claimant's Attorney OBA #