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Answer And Notice Of Contested Issues CC-Form-10 - Oklahoma

Answer And Notice Of Contested Issues Form. This is a Oklahoma form and can be used in Workers Comp .
 Fillable pdf Last Modified 3/14/2014
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CC-FORM-10 Send original to: or er o en a on o to lai ant or t e lai ant Re ord, i an i ion and orne o o WORKERS' COMPENSATION COMMISSION 9 5 NORTH STILES VENUE OKL HOM ITY, OKL HOM 73 05 THIS SP E FOR OMMISSION USE ONLY In re claim of: Full Na e o Injured E lo ee ( lai ant) lai ant So ial Se urit Nu ber (L ST 4 DIGITS ONLY) XXX-XX-_____________________ Na e o E lo er (Re ondent) ANSWER AND NOTICE OF CONTESTED ISSUES OMMISSION FILE NO. i ion roved Individual Sel -In ured or E lo er In uran e arrier, Per it # or o Own Ri Grou , Unin ured Date o Injur NOTE: Mediation is available to help resolve certain workers' compensation disputes. For information, call (405) 522-8760 or In-State Toll Free (800) 522-8210. YES NO (Plea e T e or Print) ________ ________ ________ ________ ________ ________ ________ ________ ________ ________ ________ ________ ________ ________ ________ ________ ________ ________ . a lai ant at t e e o t e alleged injur , an e lo ee o t e re ondent na ed above . a lai ant overed b t e d ini tra ve or er o en a on t, Title 5 o t e O la o a Statute 3. Did lai ant u tain an a idental injur , u ula ve trau a or u er an o u a onal di ea e or illne ari ing out o and in t e our e o t e e lo ent 4. Ha lai ant led a lai or o en a on (i.e. a -For -3 or -For -3 ) wit in t e tatutor eriod o e 5. Did re ondent, at t e e o t e alleged injur , ave an own-ri er it or a o en a on in uran e oli wit t e arrier na ed above . Did lai ant el no re ondent o t e injur 7. Ha lai ant been rovided edi al treat ent . Ha re ondent o en ed a ent o te orar total di abilit a ent to lai ant Te orar total di abilit a been aid to lai ant ro ________________________ to ______________________ or a total o _______________________ wee in t e total u o $______________________________ . 9. Ha re ondent ele ted a trea ng i ian Na e o trea ng i ian: _______________________________________________________________________________ . ALL DEPOSITIONS OF MEDICAL EXPERTS SHALL E COMPLETED PRIOR TO THE HEARING EFORE THE ADMINISTRATIVE LAW JUDGE ________ ________ 0. I rate an i ue lai ant o en a on rate: TTD __________________ PPD________________. . State all a r a ve de en e : ______________________________________________________________________________________________ ________________________________________________________________________________________________________________________ . Li t t e na e o all witne e w o a be alled b re ondent at earing: _______________________________________________________ ________________________________________________________________________________________________________________________ 3. Li t all ex ibit to be introdu ed at earing: ___________________________________________________________________________________ ________________________________________________________________________________________________________________________ 4. Re ondent ereb er e t at a o o t e edi al re ort wri en b Dr. _________________________________________________, and dated __________________________________________, wa ailed, toget er wit a o o t i NS ER ND NOTI E, to t e O o ing Part / oun el. LIST ON A SEPARATE SHEET ADDITIONAL WITNESSES EXHI ITS AND MEDICAL EVIDENCE If com en abili y of a claim i con e e he re on en hall com le e i co ery an claiman ' ling of a claim for com en a on A O S 111 ecure a me ical e alua on of he claiman wi hin ix y 0 ay of he A mini ra e Wor er ' Com en a on Ac A OS A 1 a: n er on or en t w o a e an aterial al e tate ent or re re enta on, w o will ull and nowingl o it or on eal an aterial in or a on, or w o e lo an devi e, e e, or ar e, or w o aid and abet an er on or t e ur o e o : ( ) obtaining an bene t or a ent ... all be guilt o a elon ." n er on w o o it wor er o en a on raud, u on onvi on, all be guilt o a elon uni able b i ri on ent, a ne or bot . T e under igned de lare under PEN LTY OF PERJURY t at t e belie , t e are true, orre t and o lete. ave exa ined all tate ent ontained erein, and to t e be t o t eir nowledge and Signed t i __________da o __________________________________,____________. Signa ure of Re on en In urer Coun el for Re on en /In urer THE RESPONDENT/INSURER HERE Y CERTIFY THAT A COPY HAS EEN SENT TO: O o ing Par y/Coun el A re Number & S ree A re Number & S ree Ci y Sae Zi Co e Ci y Sae Zi Co e Tele hone # of Filing Par y Prin or y e Name of A orney Crea e 2-1-14 O A# American LegalNet, Inc. www.FormsWorkFlow.com
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