Oklahoma > Workers Comp

Verification Of Permanent Total Disability CC-Form-V - Oklahoma

Verification Of Permanent Total Disability Form. This is a Oklahoma form and can be used in Workers Comp .
 Fillable pdf Last Modified 3/14/2014
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F C MMISSI N SE NL CC-FORM-V OKLAHOMA WORKERS' COMPENSATION COMMISSION 1915 N KLAH MA CI H S ILES AVEN E KLAH MA 73105 (405) 522-3222 or In-State oll Free (800) 522-8210 VERIFICATION OF PERMANENT TOTAL DISABILITY (Please print legibly in ink.) Full Name of Employee: Address _________________________________________________________________________________________________________ _________________________________________________________________________________________________________ _________________________________________________________________________________________________________ City State Zip Commission File No.: ____________________________________ Employee's Social Security No. (Last 4 digits only.): XXX-XX-_________________ Name of Employer: _______________________________________ Date of Injury: ______________________ I ______________________________________ do ere y cer fy and a rm under ENAL FE t at I am permanently and totally disa led due to my work-related condi on and not capa le of gainful employment. Also I am not presently nor a e I een gainfully employed since I ecame permanently and totally disa led. I furt er cer fy t at a copy ereof was sent to t e insurance carrier or self-insured employer on t e date and at t e address noted elow. Insuran e Carrier/Self-Insured E pl yer/C unsel Address (Nu ber & Street) City State Zip C de Dated t is ________________day of________________________________________________ 2_________. ______________________________________________ Signature State of __________________________ County of _________________________ S BSC IBED AND SW 2___________. __________________________________________________ N My Commission Expires: _____________________________________ A BLIC N efore me a Notary u lic on t is _____________ day of _________________________________ Ad inistra e W rkers' C pensa n A t A O.S. (A)(1)(a) Any person or en ty w o makes any material false statement or representa on w o willfully and knowingly omits or conceals any material informa on or w o employs any de ice sc eme or ar ce or w o aids and a ets any person for t e purpose of: (1) o taining any ene t or payment s all e guilty of a felony." Any person w o commits workers' compensa on fraud upon con ic on s all e guilty of a felony punis a le y imprisonment a ne or ot . Created 2-1-14 American LegalNet, Inc. www.FormsWorkFlow.com
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