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Claimants First Notice Of Death And Claim For Compensation CC-Form-3A - Oklahoma

Claimants First Notice Of Death And Claim For Compensation 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-3A USE FOR DEATHS OCCURRING ON OR AFTER FEBRUARY 1, 2014 WORKERS' COMPENSATION COMMISSION 1915 NO TH STILES AVENUE OKLAHOMA CITY, OK 73105 Please check appropriate box I. Original Filing THIS SPACE FO COMMISSION USE ONLY Send ori inal and 4 copies to: or ers Compensa on Commission IN THE MATTER OF THE DEATH OF (deceased employee) Name of Claimant (indi idual lin claim) II. Amends Previously Filed CC-Form-3A. (Must clearly state whether amendment is in addi on to, or subs tute for, prior informa on.) Name of Employer CLAIMANT'S FIRST NOTICE OF DEATH AND CLAIM FOR COMPENSATION Commission Use Only COMMISSION FILE NO NOTE: Mediation is available to help resolve certain workers' compensation disputes. For information, (Please type or print) call (405) 522-8760 or in-state toll free (800) 522-8210. Social Security Number (LAST 4 DIGITS Phone: ONLY) ( ) XXX-XX-________________________ FULL NAME OF DECEASED EMPLOYEE (Last, First, Middle): Mailing Address (include City, State & Zip): Date of Birth: Was deceased employment agreement made in Oklahoma? YES NO Age: Sex: Occupa on: Average Weekly Wage: Claimant's Name (Last, First, Middle): Phone: ( ) Mailing Address (include City, State & Zip): Date of Accidental Injury ela onship to Deceased Time: ______________ AM Place of Injury: City/County/State PM Date of Death Time: ______________ AM Place of Death: City/County/State PM Nature of Injury Body part(s) injured Descri e ac i es hen injury occurred ith details of ho e ent occurred Include o ject or su stance hich directly injured deceased Cause of death (normally sho n on Death Cer cate) as deceased led a claim for compensa on re ardin this accident YES NO Employer: Federal ID# Telephone: Complete Mailing &/or Street Address: City: State: Zip: as a personal representa ve been appointed for the estate of the deceased YES NO If yes, state name and address of the personal representa ve below: List, on the reverse side of this form, the names, rela onships, addresses and dates of birth of all persons who were actually dependent upon the deceased at the me of death. List person or en ty (with address, phone number) which has paid bene ts under a group health, disability or loss of income policy for the injury reported on this form:___________________________________________________________________________________________________________________ Administra ve Workers' Compensa on Act, A O.S., A 1 a : Any person or en ty who makes any material false statement or representa on, who willfully and knowingly omits or conceals any material informa on, or who employs any device, scheme, or ar ce, or who aids and abets any person for the purpose of: (1) obtaining any bene t or payment ... shall be guilty of a felony." Any person who commits workers' compensa on fraud, upon convic on, shall be guilty of a felony punishable by imprisonment, a fine or both. Name of Claimant s A orney, if represented: Type or Print Name of A orney: OBA # The undersigned declare under PENALTY OF PERJURY that they have examined this o e o eat an lai or o pensa on, and all statements contained herein are true, correct and complete, to the best of their knowledge and belief. Signed this ___________ day of________________________________, ___________. Mailing Address: City State Zip Telephone #: ( ) Signature of Claimant (Must be signed by Claimant) Signature of A orney for Claimant (if any) Created 2-1-14 American LegalNet, Inc. www.FormsWorkFlow.com
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