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Request For Hearing CC-Form-9 - Oklahoma

Request For Hearing 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-9 Send original to: or er o en a on o i ion and Ea h O o ing Part / oun el o to WORKERS' COMPENSATION COMMISSION 9 5 NORTH STILES AVENUE OKLAHOMA ITY, OKLAHOMA 73 05 TI E MMI I N U E N Y In re claim of: Full Na e of lai ant (Injured E lo ee) lai ant So ial Se urit Nu ber (LAST 4 DIGITS ONLY) XXX-XX-________________________ REQUEST FOR HEARING Commission File Number Na e of E lo er (Re ondent) Employer's Insurance arrier ermit # for ommission ppro ed Indi idual elf-Insured or Group elf-Insurance ssocia on Date of Injury NOTE: Mediation is available to help resolve certain workers' compensation disputes. For information, call (405) 522-8760 or In-State Toll Free (800) 522-8210. ( lease Type or rint) 1. Issues to be tried: (Mark all applicable issues below.) a. Temporary Total Disability from ________________________ to _______________________________. b. Medical Treatment from _____________________________ to ________________________________. c. ermanent ar al Disability. d. ermanent Total Disability. e. laim for addi onal compensa on per .. for eopen on an e of ysical ondi on. as t e eopen ee been paid? YE N f. an e of ysician for a worker co ered by a er ed orkplace Medical lan ( M ). (Note: ile a - orm- to set a equest for an e of ysician w en t e worker is N T co ered by a M .) . an e of ase Mana er for a worker not co ered by er ed orkplace Medical lan ( M ). . iability of Mul ple In ury Trust und. i. ate: TTD____________________ D____________________ TD __________________ _________________. . Deat Bene ts. k. M D orm 1 ( ro ider equest for Medical ee Dispute esolu on). as t e M D orm 1 led pre iously wit t e ommission? YE N l. t er ( E I Y)__________________________________________________________________________________________. (ALL DEPOSITIONS OF MEDICAL EXPERTS SHALL BE COMPLETED PRIOR TO THE HEARING BEFORE THE ADMINISTRATIVE LAW JUDGE.) 2. 3. 4. ist t e names of all witnesses w o may be called at earin :____________________________________________________________ ______________________________________________________________________________________________________________ ist all ex ibits to be introduced at earin : __________________________________________________________________________ ______________________________________________________________________________________________________________ equestor ereby cer es t at a copy of t e medical report wri en by Dr. _________________________________________and dated _____________________________ was mailed to et er wit a copy of t e EQUE T E ING to t e pposin arty/ ounsel. o o o (REFER TO COMMISSION RULES REGARDING THE EXCHANGE OF EXHIBITS.) Do NOT CC-Fo Wo Co o Co o. A ministra e Wor ers' Com ensa on Act A OS A a : An er on or en t ho a e an aterial fal e tate ent or re re enta on, ho illfull and no ingl o it or on eal an aterial infor a on, or ho e lo an de i e, he e, or ar e, or ho aid and abet an er on for the ur o e of: ( ) obtaining an bene t or a ent ... hall be guilt of a felon ." An er on ho o it or er o en a on fraud, u on on i on, hall be guilt of a felon uni hable b i ri on ent, a ne or both. The under igned de lare under PENALTY OF PERJURY that the ha e exa ined all tate ent belief, the are true, orre t and o lete. ontained herein, and to the be t of their no ledge and i ned t is ____________day of_________________________________ ___________. I HEREBY CERTIFY THAT A COPY HAS BEEN SENT TO: Signature of Respondent Claimant Provider Counsel for Requestor Opposing Party/Counsel Address (Number & Street) Address (Number & Street) City State Zip Code City State Zip Code Telephone # of Filing Party Print or type Name of A orney Created 2-1-14 OBA # American LegalNet, Inc. www.FormsWorkFlow.com
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