Oklahoma > Workers Comp
Certificate To Compromise Settlement - Oklahoma
| Certificate To Compromise Settlement Form. This is a Oklahoma form and can be used in Workers Comp . |
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Before the Workers' Compensation Court of the State of Oklahoma In re claim of: Claimant Respondent Insurance Carrier ) ) ) ) ) ) ) WCC File Number: Claimant's Social Security Number XXX-XX-______________ (LAST 4 DIGITS ONLY) CERTIFICATE TO COMPROMISE SETTLEMENT 1. The claimant certifies that the Respondent has been notified 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 to notify all future medical providers for the accidental injury while employed by the Respondent that the claim against the Respondent has been fully settled by Compromise Settlement. Claimant 2. The Respondent's attorney certifies that a copy of the Compromise 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 Compromise Settlement specifies that the Respondent will not be responsible for treatment rendered after the date of the Compromise Settlement. Respondent - over 08/26/11 American LegalNet, Inc. www.FormsWorkFlow.com EXHIBIT "A" TO CERTIFICATE TO COMPROMISE SETTLEMENT 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 American LegalNet, Inc. www.FormsWorkFlow.com
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