Oklahoma > Workers Comp

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
Get this form for FREE as a print-only pdf

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
Link/Embed this Document
URL
Embed


Popular Searches

  1. bill of costs
  2. Request for entry of default
  3. stipulation of discontinuance
  4. Preliminary Change of Ownership Report
  5. Notice and Acknowledgment of Receipt
  6. Decree of Dissolution of Marriage
  7. proof of service of summons
  8. Petition to Expunge
  9. writ of replevin
  10. fEE WAIVER

Bookmark and Share