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Employees First Notice Of Occupational Disease And Claim For Compensation CC-Form-3B - Oklahoma

Employees First Notice Of Occupational Disease 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-3B USE FOR OCCUPATIONAL DISEASE/ILLNESS OCCURRING ON OR AFTER FEBRUARY 1, 2014 WORKERS' COMPENSATION COMMISSION 1915 NOR H S ILES VENUE OKL HO I Y, OK 7 105 P I E ) HIS SP E OR O ISSION USE ONLY S 4 : O P ( , f, f ) -B N f (I II N fE EMPLOYEE'S FIRST NOTICE OF OCCUPATIONAL DISEASE AND CLAIM FOR COMPENSATION COMMISSION FILE NO. 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. (Please type or print) : S S N (L S 4 DIGI S P FULL NAME OF EMPLOYEE (L , , ): ONLY): ( ) NOTE: A voluntary Mediation Program to address certain workers' compensationXXX-XX- ___________________ the Workers' Compensation Court. For infordisputes is available through mation, call (405) 522-8760 S (800)Z522-8210. S: D fB : : ( , or & ): O : : O ? YES NO L D f fE :Y ______ _______ : __________________________ Date of last exposure to hazard which caused disease: D f f : P fI : / /S N fD ( :R f ) B P ( )I : D f I : Hv YES u fil d cl S c l S cu Ds bl I su c fi s? wh C u l g bl hs s ? M dc h fil g YES fis hs w ll c ub c ccu l g bl M dc lDs s d Cl fis I Employer: f f " - -" E I EI # ( ID N ): f - f : ? _______ If "YES", : : S : Z: S (f ff f ): : S : Z: Admi istra e Wor ers' Compe sa o Act, , f f f: (1) A O.S., A 1 a: " f ... , ff " , , f , A y perso who commits wor ers' compe sa o fraud, upo co ic o , shall e uilty of a felo y pu isha le y impriso me t, a fi e or oth. CLAIM INFORMATION (Please Print) Is h s cl ini al b fi s(. . b fis h dc l d hv b c v d)? YES Is h s cl addi onal b fi s ( .g. dd l lds bl dd l d c l)? YES _____________________________________________________________________________________________________________________________ s hs Cl s (w h dd ss h u b ) wh ch h s d b fi su d g u h l h ds bl l ss c lc h ju d ___________________________________________________________________________________________________________________ s s d The u dersi ed declare u der PENALTY OF PERJURY that they ha e exami ed this , and all statements contained herein are true, correct and complete, to the best of their knowledge and belief. Sg S Z M l g dd ss d h s _______________ d _____________________________ __________ C Sg l ( h ) u Cl (Mus b s g d b Cl ) Sg Created 2-1-14 u Cl ( ) American LegalNet, Inc. www.FormsWorkFlow.com
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