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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: Workers' Compensation Commission and 1 copy to Claimant or the Claimant's Attorney of Record, if any In re claim of: Full Name of Injured Employee (Claimant) WORKERS' COMPENSATION COMMISSION 1915 NORTH STILES AVENUE STE 231 OKLAHOMA CITY, OKLAHOMA 73105 THIS SPACE FOR COMMISSION USE ONLY Claimant's Social Security Number (LAST 4 DIGITS ONLY) XXX-XX-_____________________ Name of Employer (Respondent) Employer's Insurance Carrier, Permit # for Commission Approved Individual Self-Insured or Own Risk Group, Uninsured ANSWER AND NOTICE OF CONTESTED ISSUES COMMISSION FILE NO. Date of Injury NOTE: Mediation is available to help resolve certain workers' compensation disputes. For information, call (405) 522-5308 or In-State Toll Free (855) 291-3612. YES NO (Please Type or Print) ________ ________ ________ ________ ________ ________ ________ ________ ________ ________ ________ ________ ________ ________ ________ ________ ________ ________ 1. Was claimant at the time of the alleged injury, an employee of the respondent named above? 2. Was claimant covered by the Administrative Workers' Compensation Act, Title 85A of the Oklahoma Statutes? 3. Did claimant sustain an accidental injury, cumulative trauma or suffer an occupational disease or illness arising out of and in the course of the employment? 4. Has claimant filed a claim for compensation (i.e. a CC-Form-3 or CC-Form-3B) within the statutory period of time? 5. Did respondent, at the time of the alleged injury, have an own-risk permit or a compensation insurance policy with the carrier named above? 6. Did claimant timely notify respondent of the injury? 7. Has claimant been provided medical treatment? 8. Has respondent commenced payment of temporary total disability payments to claimant? Temporary total disability has been paid to claimant from ________________________ to ______________________ for a total of _______________________ weeks in the total sum of $______________________________ . 9. Has respondent selected a treating physician? Name of treating physician: _________________________________________ . (ALL DEPOSITIONS OF MEDICAL EXPERTS SHALL BE COMPLETED PRIOR TO THE HEARING BEFORE THE ADMINISTRATIVE LAW JUDGE) ________ ________ 10. Is rate an issue? Claimant's compensation rate: TTD __________________ PPD________________. 11. State all affirmative defenses: ______________________________________________________________________________________________ ________________________________________________________________________________________________________________________ 12. List the names of all witnesses who may be called by respondent at hearing: _______________________________________________________ ________________________________________________________________________________________________________________________ 13. List all exhibits to be introduced at hearing: ___________________________________________________________________________________ ________________________________________________________________________________________________________________________ 14. Respondent hereby certifies that a copy of the medical report written by Dr. _________________________________________________, and dated __________________________________________, was mailed, together with a copy of this ANSWER AND NOTICE, to the Opposing Party/Counsel. Refer to Commission rules on exchange of exhibits. DO NOT attach a copy of the medical report when filing the CC-Form-10 with the Commission. (LIST ON A SEPARATE SHEET, ADDITIONAL WITNESSES, EXHIBITS AND MEDICAL EVIDENCE) If compensability of a claim is contested, the respondent shall complete discovery and secure a medical evaluation of the claimant within sixty (60) days of the claimant's filing of a claim for compensation. 85A O.S., §111(C). Administrative Workers' Compensation Act, 85A O.S., §6(A)(1)(a): "Any person or entity who makes any material false statement or representation, who willfully and knowingly omits or conceals any material information, or who employs any device, scheme, or artifice, or who aids and abets any person for the purpose of: (1) obtaining any benefit or payment ... shall be guilty of a felony." Any person who commits workers' compensation fraud, upon conviction, shall be guilty of a felony punishable by imprisonment, a fine or both. The undersigned declare under PENALTY OF PERJURY that they have examined all statements contained herein, and to the best of their knowledge and belief, they are true, correct and complete. Signed this __________day of__________________________________,____________. THE RESPONDENT/INSURER HEREBY CERTIFY THAT A COPY HAS BEEN SENT TO: Opposing Party/Counsel Address (Number & Street) City State Zip Code Signature of Respondent Insurer Counsel for Respondent/Insurer Address (Number & Street) City Telephone # of Filing Party Print or type Name of Attorney Revised 2-2-16 American LegalNet, Inc. www.FormsWorkFlow.com State Zip Code OBA #
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