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Employers First Notice Of Injury CC-Form-2 - Oklahoma

Employers First Notice Of Injury Form. This is a Oklahoma form and can be used in Workers Comp .
 Fillable pdf Last Modified 2/25/2014
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CC-FORM-2 Applicable to Injuries /Deaths Occurring On or After 2/1/14 Send original to Workers' Compensation Commission and 1 copy to Insurance Carrier Please type or print. Enter all dates in MM/DD/YY format. Full Name of Employee - LAST, FIRST, MIDDLE WORKERS' COMPENSATION COMMISSION 1915 NORTH STILES AVENUE STE 231 OKLAHOMA CITY, OK 73105 THIS SPACE FOR COMMISSION USE ONLY EMPLOYER'S FIRST NOTICE OF INJURY Employee Email Address Complete Address City State Zip Telephone Number Employee's Social Security Number (LAST 4 DIGITS ONLY) XXX-XX-________________________ Date of Birth Sex Length of Employment: Years Months _______ Date of Hire:__________________________________ Average Weekly Wage Occupation (job description) Was employment agreement made in Oklahoma? YES NO 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. Date of accident or last exposure Time of accident or exposure o'clock Last date employee worked Has employee returned to work? YES OSHA Log Case # AM PM Date Employer Notified Time workday began o'clock AM PM Did the employee die? YES NO If yes, on what date ? __________________________ Place of Accident or Occurrence City: County: NO If yes, on what date ?__________________________________________ State: Injury Resulted from: Nature of Injury or Illness Single Incident Cumulative Trauma Occupational Disease YES Does employee participate in a certified workplace medical plan: If yes, name of CWMP: NO Describe activities when injury occurred with details of how event occurred. Include object or substance which directly injured the employee. Identify part(s) of body involved in injury or illness Full Name and address of Treating Physician (please be complete) Employer's Insurance Carrier or Own Risk Group Name Address Employer's Name and Complete Address Name Address Type of business (Example: manufacturing, food service, construction) Federal ID# City Phone City Policy/Self-Insured Number Policy Period: From State To Zip Phone # State Zip NAICS Number Type of Ownership: Private State Government County Government Local Government Administrative Workers' Compensation Act, 85A O.S., ยง6(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 hereby declares under PENALTY OF PERJURY that they have examined this notice and all statements contained herein are true, correct and complete, to the best of their knowledge. The undersigned certifies this CC-Form 2 was sent to the Workers' Compensation Commission and a copy thereof to the employer's insurer on the date noted below: Signed By Telephone Number Date American LegalNet, Inc. www.FormsWorkFlow.com Signature of Preparer Name and Title of Preparer (Please Print) Area Code and Number A CC-Form 2 must be sent to the Workers' Compensation Commission and to the employer's workers' compensation insurance carrier within 10 days after the date of receipt of notice or knowledge of death or injury that results in more than three days' absence from work for the injured employee. PROVIDING THIS FORM TO THE COMMISSION IS NOT EVIDENCE OF ANY FACT STATED IN THE REPORT IN ANY PROCEEDING WITH RESPECT TO THE INJURY OR DEATH ON ACCOUNT OF WHICH THE REPORT IS MADE. Revised 2-2-16
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