Oklahoma > Workers Comp

Joint Petition Settlement Appendix Form-JP-Appendix - Oklahoma

Joint Petition Settlement Appendix Form. This is a Oklahoma form and can be used in Workers Comp .
 Fillable pdf Last Modified 3/14/2014
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FORM JP-APPENDIX WORKERS' COMPENSATION COMMISSION 1915 NORTH STILES AVENUE OKLAHOMA CITY, OK 73105 THIS SPACE FOR COMMISSION USE ONLY JOINT PETITION SETTLEMENT APPENDIX In re Claim of: (Please type or Print ALL information legibly in ink.) Full Name of Injured Employee Injured Employee's Social Security Number (LAST 4 DIGITS ONLY) XXX­ XX-_____________________________ Name of Employer Commission File Number Employer's Insurance Carrier, Permit # for Commission Approved Individual Self-Insured or Own Risk Group, Uninsured Date of Injury Use and attach to a CC-Joint Petition ONLY IF the Joint Petition Settlement seeks to settle and determine SOME, BUT NOT ALL, issues and matters in the claim. Identify the outstanding issues that are subject to the Commission's continuing jurisdiction. NOTE: The original and five (5) copies of the Joint Petition Settlement with Appendix attached are required when the settlement order is submitted to the Workers' Compensation Commission for filing. By signing below, each party affirms that they have read and understand the provisions of this JOINT PETITION SETTLEMENT APPENDIX, declares under penalty of perjury that all statements are true and accurate to the best of their knowledge and belief, and understands that the Joint Petition Settlement Appendix, if approved by the Workers' Compensation Commission, is conclusive, final and binding on all parties involved. 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. _____________________________________________________________________ Name of Claimant X ____________________________________________________________________ Signature of Claimant DATE _____________________________________________________________________ Address of Claimant ____________________________________________________________________ Type or Print Name of Claimant's Attorney, if any OBA# X____________________________________________________________________ Created 2-1-14 __________________________________________________________________ Name of Respondent __________________________________________________________________ Name of Insurance Carrier or Own Risk Group __________________________________________________________________ Type or Print Name of Respondent/Insurer Attorney OBA# X________________________________________________________________ Signature of Respondent/Insurer Attorney DATE American LegalNet, Inc. www.FormsWorkFlow.com
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