Send Original and 3 copies to Workers' Compensation Court Full Name of Claimant (Injured Employee) Claimant's Social Security Number Name of Respondent (Employer)
WORKERS COMPENSATION COURT 1915 NORTH STILES OKLAHOMA CITY, OK 73105-4918
THIS SPACE FOR COURT USE ONLY
MEMORANDUM OF AGREEMENT AS TO FACT WITH RELATION TO AN INJURY AND PAYMENT OF DISABILITY COMPENSATION FILE NO. Date of Injury
Employer's Insurance Carrier, Permit # for Court Approved Individual SelfInsured or Own Risk Group, Uninsured (Please type or Print ALL information legibly in ink)
We, the above named parties, agree to pay and accept compensation as provided herein based on the following facts and pursuant to 85 O.S., Section 26: 1. That the claimant sustained an accidental injury on __________________________, ______, at (time) _________ arising out of and in the course of employment with the employer. The nature of the injury was _________________________________________________, resulting in temporary total disability from _______________________, _________ to ________________________, _________ or for a period of _________ weeks, for which claimant received $____________________ in compensation, computed at _____________per week, based upon claimant's hourly wage of ____________. That claimant timely notified the employer of the injury; that claimant's employment was covered by the Workers' Compensation Act and that this Court has jurisdiction in the matter. That as a result of the injury, respondent or insurance carrier agrees to pay to the claimant the sum of $_____________________, same being for permanent disability (_______%) to ____________________________________________________________; to pay authorized, reasonable and necessary medical expenses incurred by claimant by reason of the injury, and comply herewith within 20 days of the file-stamped date of this Form 26. The sum of $____________________ shall be deducted from this settlement amount and paid to the claimant's attorney as a fair and reasonable fee. Claimant ACCEPTS the fee amount and payment method, and WAIVES THE RIGHT TO A FEE HEARING (____claimant's initials). Claimant REJECTS the fee amount and payment method and REQUESTS A FEE HEARING (____claimant's initials). The respondent or insurance carrier shall pay court costs in the amount of $75.00, in each case, unless the Court cost was previously paid; the Special Occupational Health and Safety Tax in the sum of $_______________________, representing three-fourths of one percent (0.75%) of the entire settlement amount, excluding medical payments and temporary total disability; and the respondent, if OWN RISK, shall also pay the sum of $____________________, representing 2% of the total compensation for permanent disability and death benefits to the Workers' Compensation Administration Fund and the sum of $_____________________, representing 1% of the total compensation for permanent partial disability to the appropriate Self-Insured Guaranty Fund, if applicable by law. In addition to other amounts, the respondent, if UNINSURED, shall pay a Multiple Injury Trust Fund assessment in the sum of $_______________________, representing 5% of the total compensation paid for permanent disability and death benefits. It is further agreed by and between the above named parties that this agreement shall not be final if a change in claimant's condition occurs or arises, in which case, the agreement may be reopened and reviewed in the same manner as a change of condition.
We, the undersigned, declare under penalty of perjury that we have examined this agreement and all statements contained herein, and to the best of our knowledge and belief, they are true, correct and complete. ANY PERSON WHO COMMITS WORKERS' COMPENSATION FRAUD, UPON CONVICTION, SHALL BE GUILTY OF A FELONY.
Signed this _____ day of ____________________, _______. Signature of Claimant X Claimant's Address Name of Claimant's Attorney OBA #
Signed this _____ day of ____________________, _______. Employer or Respondent
Name of Insurance Carrier or Own Risk Group Type or Print Name of Attorney for Respondent/Insurer OBA #
Signature of Claimant's Attorney X
Signature of Attorney for Respondent/Insurer X