Oklahoma > Workers Comp

Report Of Compensation Paid-Suspension Of Payments CC-Form-4 - Oklahoma

Report Of Compensation Paid-Suspension Of Payments 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-4 S rg rrC E : C rB fic r 1 c OKLAHOMA WORKERS' COMPENSATION COMMISSION 1915 NORTH STILES AVENUE OKLAHOMA CITY, OKLAHOMA 73105 (405) 522-3222 r I -S T Fr (800) 522-8210 FOR COMMISSION USE ONLY REPORT OF COMPENSATION PAID/SUSPENSION OF PAYMENTS AMENDED REPORT Closing Report Report of Payment Suspension Commission File No. Death/PTD Maximum Liability Update Report ( Full Employee Name (Last, First, MI) ) Employee Social Security No. (Last 4 digits only) Carrier Claim No. Employer Name City State Zip Code Carrier or Self-Insured Name Claims O ce Loca on (mailing address) DISABILITY INFORMATION Date of Injury Last Day Employee Worked Date Employee Able to RTW Return-to-Work (RTW) Date T wr bw jur b RT : _____________ COMPENSATION INFORMATION: COMPENSATION PAYMENTS MADE: (1) TT (2) TP (3) PP (4) ______ (5) ______ (6) Lu (7) (8) C Su P A S r F ______ ______ ______ PT r ______ ______ ______ $ ________________________ ________________________ ________________________ ________________________ ________________________ ________________________ ________________________ ________________________ (9) (10) O (11) H (12) M (13) r (C Ex c Ex c A r F R ) ________________________________ _______ _________________________ ________________________________ ________________________________ ________________________________ ________________________________ ________________________________ R ) ________________________________ ________________________________ rug , M r Ex b r (Ex (14) Fu (15) R (16) O (1 - 16) GRAN TOTAL SUSPENSION OF PAYMENTS OF COMPENSATION Su C : __________________ R r Su : _________________________________________________________________ _______________________________________________________________________________________________________________________________________ C r ug ____________________________ ( ) CERTIFICATION Ic r u u r PENALTY OF PER URY r Signature I ur rg g rc r c c ccur r r cc r r rru g r rcr b r Title ur r r g rb c fic r Date Printed or Type ri en Name Created 2-1-14 American LegalNet, Inc. www.FormsWorkFlow.com CC-FORM-4 (Report of Payment) Questions about the CC-Form-4, or general information or assistance on completing or filing a CC-Form-4, may be directed to the Workers' Compensation Commission Counselor Division, (405) 522-8760 or In-State Toll Free (800) 522-8210. Administra e Workers' Compensa on Act, A O.S., r rr r ,w w u r , rw c, c ,r r ur : (1) b g b fir ... b A r w c wr r c ru u bb r ,fi rb A wg fic , r w gu ,u c c (A)(1)(a): r " , r rc b b c gu w r r r American LegalNet, Inc. www.FormsWorkFlow.com
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