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Employees First Notice Of Claim For Compensation CC-Form-3 - Oklahoma

Employees First Notice Of Claim For Compensation 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-3 USE FOR ACCIDENTAL INJURY OR CUMULATIVE TRAUMA OCCURRING ON OR AFTER FEBRUARY 1, 2014 WORKERS' COMPENSATION COMMISSION 1915 NOR H S ILES VENUE OKL HO CI Y, OK 7 105 P HIS SP CE OR CO ISSION USE ONLY S C 4 C : N fC (I E ) I II O P ( , f, f ) CC- N C fE U O EMPLOYEE'S FIRST NOTICE OF CLAIM FOR COMPENSATION 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. CO ISSION ILE NO (Please type or print) FULL NAME OF EMPLOYEE (L , , ): S S N (L S 4 DIGI S ONLY): ( O : C ,S & Z ): XXX-XX-_______________________________ D f : : P ( : ) S: :Y ______ _______ : O ? YES NO L D fE fH : Date of Accident/Injury I S I f : C I O P __________________ D f ff P fI :C /C /S f I I : D I : H ? YES NO f S S D I f YES NO f f N fC f C ? f 0 "CCTrea n P y ician fu na e f -" C : C I C : S : I ? _______ If "YES", Z: E p oyer E EI # ( ID N ): C : C : S : Z: C S (f ff f ): C : S : Z: Ad ini tra f f Any per on e Wor er ' Co pen a on Act, f: (1) o co it AOS, A1a f ... " , a ff " , , f , , or er ' co pen a on fraud, upon con ic on, e ui ty of a fe ony puni a e y i pri on ent, a fine or ot CLAIM INFORMATION (Please Print) Is this a claim for ini al benefits (i.e. no benefits, either medical or indemnity, have been received)? YES NO Is this a claim for addi onal benefits (e.g. addi onal tem orary total disability, addi onal medical)? YES NO _____________________________________________________________________________________________________________________________ ist erson or en ty ( ith address, hone n mber) hich has aid benefits nder a gro health, disability or loss of income olicy for the inj ry re orted on this form:___________________________________________________________________________________________________________________ N f P f N f : : O # T e under i ned dec are under PENALTY OF PERJURY t at t ey a e exa ined ti , and all statements contained herein are true, correct and complete, to the best of their knowledge and belief. Signed this ______ day of __________________________________ , ________. : C S Z S fC ( C ) ( #: ) S Created 2-1-14 f f C (f ) American LegalNet, Inc. www.FormsWorkFlow.com
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