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Claimants Application And Order For Dismissal CC-Form-100 - Oklahoma

Claimants Application And Order For Dismissal Form. This is a Oklahoma form and can be used in Workers Comp .
 Fillable pdf Last Modified 3/18/2014
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CC-FORM-100 Send original and 3 copies to: Workers' Compensation Commission In re claim of: Full Name of Claimant (Injured Employee) Claimant's Social Security Number (LAST 4 DIGITS ONLY) XXX-XX-_________________________ Name of Employer (Respondent) WORKERS COMPENSATION COMMISSION 1915 NORTH STILES AVENUE STE 231 OKLAHOMA CITY, OKLAHOMA 73105 THIS SPACE FOR COMMISSION USE ONLY CLAIMANT'S APPLICATION AND ORDER FOR DISMISSAL COMMISSION FILE NO. Employer's Insurance Carrier, Permit # for Commission Approved Individual Self-insured or Own Risk Group Date of Injury The claimant moves to DISMISS the claim noted above as provided in 85A O.S. §108 and Commission Rule 810:10-5-85(c). In support thereof, the claimant states: YES _______ _______ NO _______ _______ Please mark the appropriate YES/NO response to the left of each numbered question. 1. 2. 3. Attached hereto is a receipt showing payment of the $140.00 dismissal fee or an executed payment plan approved by the Commission's business office. (Payment of the fee is required before the dismissal is effective. 85A O.S., §108.) The claimant is represented by counsel. A permanent total disability order, permanent partial disability order, or Joint Petition Settlement has been entered. (An order of dismissal is allowed at any time before final submission of the case to the Commission for decision. 85A O.S., §108.) _______ _______ _______ _______ 4. This request is for a dismissal with prejudice. (Before entering an order for dismissal with prejudice, the Commission may require an evidentiary hearing.) Note: If a workers' compensation claim is timely filed and then dismissed WITHOUT prejudice, the claim may be refiled within one (1) year from the date the Order of Dismissal Without Prejudice is filed, even if the limitations period has run. Any person who commits workers' compensation fraud, upon conviction, shall be guilty of a felony punishable by imprisonment, a fine or both. I declare under PENALTY OF PERJURY that I have examined all statements contained herein and they are true, correct and complete, to the best of my knowledge and belief. I HEREBY CERTIFY THAT A COPY HAS BEEN SENT TO: Opposing Party(ies) Address (Number & Street) City Claimant Address (Number & Street) City Telephone # of Claimant State Zip Code Signature of Attorney of Claimant, if any State Zip Code Print or type name of Attorney for Claimant, if any OBA # Signed this ___________ day of _____________________, _________ Signature of Claimant IT IS THEREFORE ORDERED, for good cause shown, that the above captioned claim is dismissed : _______ With Prejudice ________ Without Prejudice The filing of this order does not adjudicate the rights of any health care provider that has provided reasonable and necessary medical care to the claimant for a work related injury. BY ORDER OF _____________________________________________________________ ____________________________ Administrative Law Judge Date of Order Revised 2-8-17 American LegalNet, Inc. www.FormsWorkFlow.com
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