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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: or ers Co pensa on Co ission WORKERS COMPENSATION COMMISSION 1915 NORTH STILES AVENUE OKLAHOMA CITY, OKLAHOMA 73105 THIS SPACE FOR COMMISSION USE ONLY In re claim of: Full Na e of Clai ant (Injured E ployee) Clai ant s Social Security Nu ber (LAST 4 DIGITS ONLY) XXX-XX-_________________________ Na e of E ployer (Respondent) CLAIMANT'S APPLICATION AND ORDER FOR DISMISSAL COMMISSION FILE NO. ission Approved Individual Self-insured or Own E ployer s Insurance Carrier, Per it # for Co Ris Group Date of Injury The clai ant oves to DISMISS the clai thereof, the clai ant states: noted above as provided in 85A O.S. ยง108 and Co ission Rule 810:2-5-85(c). In support YES _______ NO _______ Please ar the appropriate YES NO response to the le of each nu bered ues on. 1. The ling fee of 140.00 has been paid and a receipt showing pay ent is a ached to this applica on. _______ _______ 2. The clai ant is represented by counsel. _______ _______ 3 A per anent total disability order, per anent par al disability order, or oint Pe entered. on Se le ent has been _______ _______ 4. This re uest is for a dis issal with prejudice. g B g pj (1) Any er on oo t or er ' o en a on frau u on on ne a on a e u ty of a fe ony un aey r on ent a fine or ot . o ete to t e e t of y I e are un er PENALTY OF PERJURY t at I a e exa no e e an e ef. I HEREBY CERTIFY THAT A COPY HAS BEEN SENT TO: tate ent onta ne ere n an t ey are true orre t an O o n Party( e ) Signed this ___________ day of _____________________, _________ S nature of C a Z Co e A re (Nu er & Street) ant C ty State Pr nt or ty e na e of A orney for C a Ca ant ant f any OBA # A re (Nu er & Street) S nature of A orney of C a Z Co e ant f any C ty State Te e one # of C a ant IT IS THEREFORE ORDERED, for good cause shown, that the above cap oned clai _______ W j ________ W j T g k j j g p is dis issed : p BY ORDER OF _____________________________________________________________ ____________________________ Date of Or er Created 2-1-14 American LegalNet, Inc. www.FormsWorkFlow.com
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