Claimants First Notice Of Death And Claim For Compensation {CC-Form-3A}

CC-FORM-3A - CLAIMANT’S FIRST NOTICE OF DEATH AND CLAIM FOR COMPENSATION. This form is used by the Oklahoma Workers’ Compensation Commission for workplace-related deaths that occurred on or after February 1, 2014. This form is completed by an individual, such as a surviving family member or dependent, seeking workers’ compensation benefits due to the death of an employee resulting from a workplace injury or occupational disease. It collects essential information about the deceased employee, including their name, Social Security number, date of birth, occupation, and details of the fatal accident. The claimant must provide their personal details, relationship to the deceased, and information about any dependents. The form also asks whether a personal representative has been appointed for the deceased’s estate and requires details about any benefits paid by a group health, disability, or loss of income policy. www.FormsWorkflow.com