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Employers Application And Authorization For Extension Of Time To File CC-Form-2A Extension - Oklahoma

Employers Application And Authorization For Extension Of Time To File 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-2A Extension WORKERS COMPENSATION COMMISSION 1915 NORTH STILES AVENUE STE 231 OKLAHOMA CITY, OKLAHOMA 73105 THIS SPACE FOR COMMISSION USE ONLY Send to Workers' Compensation Commission, ATTN: FORM 2 DIVISION, and send 1 copy to the Employee or Beneficiaries Please type or print. Enter dates in MM/DD/YY format. Full Name of Employee Employee'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 Date of Injury/Death Date Employer Received Notice or Knowledge of Injury/Death COMMISSION FILE NO. if any EMPLOYER'S APPLICATION AND AUTHORIZATION FOR EXTENSION OF TIME TO FILE CC-FORM-2A The employer/insurer respectfully requests one extension of the deadline to file a CC-Form-2A (Employer's Intent to Controvert Claim) as authorized in 85A O.S., §86(B), and understands that no additional extensions are allowed. In support of this application, the employer/insurer states as follows: 1. This request is postmarked to the Workers' Compensation Commission within fifteen (15) days of the employer's notice or knowledge of the above noted alleged injury or death. The fifteenth day is ___________________________, _________, calculated as provided in 85A O.S., §125 and Commission Rule 810:10-1-13 by excluding the first day and including the last day, unless the last day is a legal holiday, Saturday or Sunday, in which case the last day is the next business day. Although the employer/insurer has acted in good faith and with due diligence, the employer/insurer is unable to obtain sufficient medical information as to the alleged injury or death within the fifteen (15) day period referred to in paragraph 1 of this application and requires additional time for investigation. This request is not brought for any improper purpose, such as to harass or cause unnecessary delay or needless increase in the cost of litigation. 2. 3. 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. CERTIFICATION I certify under PENALTY OF PERJURY that I have examined this Application and all statements contained herein are true, correct and complete to the best of my knowledge and belief. I further certify that a copy of this Application has been provided to the employee or beneficiaries. Signature Printed or Typewritten Name Title:___________________________________ Phone:__________________________________ If the employer/insurer is represented by an attorney, that legal representative must sign below pursuant to 85A O.S., § 83. Name and Address of Attorney, including OBA # OBA # Date Signature (Employer's Application and Authorization for Extension of Time to File CC-Form-2A) A form used by an employer/carrier to request additional time for investigation before filing the CC-Form-2A (Employer's Intent to Controvert Claim). Help With CC-Form-2A Extension: 1. 2. 3. 4. An extension request using the "CC-Form-2A Extension" must be postmarked or delivered to the Commission before the 15-day deadline for filing of the CC-Form-2A. The 15-day deadline is calculated as provided in paragraph 1 of the extension request. An AUTOMATIC extension of 30 days beyond the 15-day deadline (for a total of 45 days from the date of the employer's notice or knowledge of the injury/death) is authorized upon submission of the CC-Form-2A Extension to the Commission as reflected by the postmark when mailed or received stamp when delivered. NO ADDITIONAL EXTENSIONS, OTHER THAN THE AUTOMATIC EXTENSION REFERRED TO IN PARAGRAPH 2, WILL BE GRANTED. No notice of the automatic extension will be provided by the Commission. The Commission may audit extension requests. Improper use of the CC-Form-2A Extension may subject the filer to sanctions. CC-Form-2A Extension Revised 2-2-16 American LegalNet, Inc. www.FormsWorkFlow.com
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