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Joint Petition Settlement CC-Joint Petition - Oklahoma

Joint Petition Settlement 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-JOINT PETITION Send original and 5 copies to the Workers' Compensation Commission In re Claim of: (Please type or Print ALL information legibly in ink.) WORKERS' COMPENSATION COMMISSION 1915 NORTH STILES AVENUE OKLAHOMA CITY, OK 73105 Commission File Number THIS SPACE FOR COMMISSION USE ONLY Claimant `s Full Name (Injured Employee) Injured Employee's Social Security Number (LAST 4 DIGITS ONLY) XXX-XX- ____________________ Name of Employer Date of Injury Employer's Insurance Carrier, Permit # for Commission Approved Individual Self-Insured or Own Risk Group, Uninsured Any person who commits workers' compensation fraud, upon conviction, shall be guilty of a felony, punishable by imprisonment, a fine or both. JOINT PETITION SETTLEMENT This agreement is prepared and submitted pursuant to Sections 87 and 115 of the Administrative Workers' Compensation Act, Title 85A of the Oklahoma Statutes. By signing below, each party affirms that they have read and understand its provisions, declares under penalty of perjury that all statements are true and accurate to the best of their knowledge and belief, and understands that the agreement, if approved by the Workers' Compensation Commission, is conclusive, final and binding on all the parties involved. BY THIS AGREEMENT, the parties settle upon and determine (check one): SOME, BUT NOT ALL, ISSUES AND MATTERS IN THE CLAIM -- Attach appendix ALL ISSUES AND MATTERS IN THE CLAIM (Settlement and Resolution of Claim With Full Release) of all outstanding issues. The appendix is subject to approval by the Workers' Compensation Commission. It MUST accompany the CC-JOINT PETITION, and be dated and signed by all parties under penalty of perjury. ) ) ) ) ) ) ) ) ) ) ) ) ) ) ) ) ) ) ) ) ) ) ) ) ) ) ) ) 1. It is hereby agreed by and between the above named parties that the claimant alleges to have sustained a compensable accidental injury or occupational disease or illness on or about ____________________________, __________, while in the employ of the employer, causing the following injury (describe nature of injury__________________________________________________________________________________________________________________, ___________________________________________and resulting in temporary total disability from _________________________________, _________ to ______________________, _______ or for a period of _______weeks, _______ days, for which the claimant received $_______________________in compensation from the employer/insurance carrier. The claimant's average weekly wage before the injury entitles the claimant to a compensation rate of $_________________ for Temporary Total Disability and $__________________ for Permanent Partial Disability. 2. A claim for compensation was filed by the claimant for the injury, or, if the claimant is not represented by an attorney, an Employer's First Notice of Injury (CCForm-2) was filed by the employer for the injury, and the Workers' Compensation Commission has jurisdiction in this matter. 3. This is an agreement in which the claimant agrees to accept $____________________ in full and final settlement of all claims for: (describe injury) __________ ____________________________________________________________________________________________________________________ sustained as a result of the accident referred to above, including any claim by the claimant for past, present and future compensation for temporary total disability, temporary partial disability, permanent partial disability or permanent total disability, statutory medical treatment, physical and vocational rehabilitation benefits, or loss of wage earning capacity, as a result of any and all injuries sustained in the accident. This sum is in addition to any previous amount(s) paid to the claimant, and any amount(s) for authorized, reasonable and necessary medical and rehabilitative expenses previously incurred by the claimant due to the injury. Of said sum, $________________________ shall be paid for permanent partial disability(________%) to ________________________________________________ ____________________________ and $________________________ shall be paid for _______________________________________________________. 4. For Social Security offset purposes, and if applicable, the claimant agrees to accept and the employer/carrier agrees to pay a lump sum of $______________________ for permanent impairment that will affect the claimant for the rest of the claimant's life. The claimant's remaining life expectancy is _______ months. Therefore, even though paid in a lump sum, claimant's benefit (after deduction of attorney fees and expenses) shall be considered to be $______________________ a month for ________ months, beginning _______________________________, _________. 5. The sum of $_____________________ shall be deducted from this settlement and paid to the claimant's attorney pursuant to the workers' compensation laws of the state. 6. The employer/carrier agrees to pay all applicable Commission costs, and all taxes and assessments to the Oklahoma Tax Commission, as follows: $140.00 to the Workers' Compensation Commission, taxed as costs in this matter, unless previously paid; the Special Occupational Health and Safety Tax in the sum of $___________________, representing three-fourths of one percent (0.75%) of the joint petition settlement amount, excluding medical payments and temporary total disability compensation; if a Commission Approved OWN RISK employer or group self-insurance association, the Workers' Compensation Fund assessment in the sum of $_____________________, representing 2% of the joint petition settlement amount, and, if applicable, the Self-insurance Guaranty Fund assessment in the sum of $_______________________, representing 1% of the joint petition settlement amount; and, in addition to other amounts, if UNINSURED, a Multiple Injury Trust Fund assessment in the sum of $________________________, representing 5% of the joint petition settlement amount. 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." CLAIMANT NAME -- PLEASE PRINT CLAIMANT ADDRESS CLAIMANT--SIGNATURE NAME OF CLAIMANT ATTO
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