Free Form 100.pub - Oklahoma

FORM 100
Send original + 3 copies to Workers' Compensation Court

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

THIS SPACE FOR COURT USE ONLY

In re claim of:
Full Name of Claimant (Injured Employee) Claimant's Social Security Number Name of Employer or Respondent Employer's Insurance Carrier, Permit # for Court Approved Individual Self-insured or Own Risk Group

CLAIMANT'S APPLICATION AND ORDER FOR DISMISSAL FILE NO.

Date of Injury

COMES NOW the CLAIMANT in the above-captioned matter and requests that this Court dismiss this claim pursuant to 85 O.S. § 43(B). In support of this application, movant states as follows: [Note: A claim may be refiled no later than 1 year from the date the "Order of Dismissal Without Prejudice" is filed, even if the statute of limitations has run.] YES
_______ _______ _______ _______

NO
_______ _______ _______ _______

Please mark the appropriate YES/NO response to the left of each numbered question.

1. The filing fee of $75.00 has been paid and a receipt evidencing payment is attached to this application. 2. The claimant is represented by counsel. 3. A permanent disability order or Settlement Agreement has been entered. 4. This request is for a dismissal with prejudice. [Prior to entering an order for dismissal with prejudice, the Court may require an evidentiary hearing.]

[NOTE: A dismissal order is permissible prior to final submission of the case to the Court for decision.] I declare under penalty of perjury that I have examined all statements contained herein, and to the best of my knowledge and belief, that 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(ies) Address (Number & Street) City Claimant Address (Number & Street) City Telephone # of Claimant State Zip Code State Zip Code

Signed this ________________ day of _________________, _______
Signature of Claimant Print or type name of Attorney for Claimant Signature of Attorney of Claimant OBA #

IT IS THEREFORE ORDERED, for good cause shown, that the above captioned case is dismissed : _______ With Prejudice ________ Without Prejudice The filing of this order does not adjudicate the rights of any health care provider that has provided reasonable and necessary medical care to the claimant for a work related injury.

BY ORDER OF _____________________________________________
2/06

________________________ Date of Order