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Before the Workers' Compensation Court of the State of Oklahoma

In re claim of: Claimant ) ) ) ) ) ) ) Court File Number:

Respondent

Insurance Carrier

Claimant's Social Security Number:

CERTIFICATE TO JOINT PETITION
1.

The claimant certifies that he has notified the Respondent of all medical providers who have provided medical treatment, including physical therapy, as a result of the accidental injury while employed by Respondent. A list of all medical providers who have provided treatment is attached hereto as Exhibit A. Further, the Claimant represents and agrees that he/she will notify all future medical providers for the accidental injury while employed by the Respondent that the claim against the Respondent has been Joint Petitioned (settled).

Claimant

2.

The Respondent's attorney certifies that a copy of the Joint Petition Settlement will be provided to all known medical providers, including physical therapists, who have provided treatment to the claimant, within ten (10) days of the settlement. The Respondent's attorney shall also notify the medical providers that the Joint Petition Settlement specifies that the Respondent will not be responsible for treatment rendered after the date of the Joint Petition.

Respondent

- over 2/06

EXHIBIT "A" TO CERTIFICATE OF JOINT PETITION
The following Medical Providers have provided medical treatment, including physical therapy, as a result of the accidental injury while employed by Respondent: Name Address, City State Zip