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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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USE FOR OCCUPATIONAL DISEASE/ILLNESS OCCURRING ON OR AFTER FEBRUARY 1, 2014 CC-FORM-3B WORKERS' COMPENSATION COMMISSION 1915 NORTH STILES AVENUE STE 231 OKLAHOMA CITY, OK 73105 Please check appropriate box I. Original Filing II. Amends Previously Filed CC-Form-3B. (Highlight the change and identify whether it adds to or replaces the prior information.) THIS SPACE FOR COMMISSION USE ONLY Send original and 4 copies to: Workers' Compensation Commission Full Name of Claimant (Injured Employee) Name of Employer EMPLOYEE'S FIRST NOTICE OF OCCUPATIONAL DISEASE AND CLAIM FOR COMPENSATION Commission use only COMMISSION FILE NO. NOTE: Mediation is available to help resolve certain workers' compensation disputes. For information, call (405) 522-5308 or in-state toll free (855) 291-3612. (Please type or print) Social Security Number (LAST 4 DIGITS Phone: ONLY): ( ) NOTE: A voluntary Mediation Program to address certain workers' compensationXXX-XX- ___________________ the Workers' Compensation Court. For infordisputes is available through mation,Address (include City, State & Zip): Sex: Mailing call (405) 522-8760 or (800) 522-8210. Date of Birth: Age: FULL NAME OF EMPLOYEE (Last, First, Middle): Occupation: Was your employment agreement in Oklahoma? YES NO Avg. Weekly Wage: Length of Employment: Years ______Months_______ Date of hire: __________________________ Date of last exposure to hazard which caused disease: Date of first distinct manifestation: Place of Injury: City/County/State Body Part(s) Injured: Nature of Disease (example: Reduced breathing capacity or loss of vision) Describe how you were exposed to the disease with details of how event occurred. Include object or substance which directly injured you: Have you filed a claim for Social Security Disability Insurance Benefits? YES NO Are you eligible for Medicare Benefits or will you become eligible for Medicare Benefits within 30 months of the filing of this Notice of Occupational Disease and Claim for Compensation? YES NO Are you a previously impaired person due to a prior workers' compensation injury or obvious and apparent pre-existing disability? _______ If "YES", you may be entitled to benefits for combined disabilities from the Multiple Injury Trust Fund. A claim for benefits for combined disabilities against the Multiple Injury Trust Fund may be commenced by filing a "CC-Form-3F" with the Workers' Compensation Commission. Employer: Complete Mailing Address: Complete Street Address (if different from above): Employer's FEI # (Federal ID Number): City: City: Telephone: State: State: Zip: Zip: Administrative Workers' Compensation Act, 85A O.S., ยง6(A)(1)(a): "Any person or entity who makes any material false statement or representation, who willfully and knowingly omits or conceals any material information, or who employs any device, scheme, or artifice, or who aids and abets any person for the purpose of: (1) obtaining any benefit or payment ... shall be guilty of a felony." Any person who commits workers' compensation fraud, upon conviction, shall be guilty of a felony punishable by imprisonment, a fine or both. CLAIM INFORMATION (Please Print) Is this a claim for initial benefits (i.e. no benefits, either medical or indemnity, have been received)? YES NO Is this a claim for additional benefits (e.g. additional temporary total disability, additional medical)? YES NO _____________________________________________________________________________________________________________________________ List person or entity (with address, phone number) which has paid benefits under a group health, disability or loss of income policy for the injury reported on this form:___________________________________________________________________________________________________________________ Name of Claimant's Attorney, if represented: Type or Print Name of Attorney: Mailing Address: City Telephone #: ( ) Signature of Attorney for Claimant (if any) Revised 2-2-16 American LegalNet, Inc. www.FormsWorkFlow.com OBA# The undersigned declare under PENALTY OF PERJURY that they have examined this Notice of Occupational Disease and Claim for Compensation, and all statements contained herein are true, correct and complete, to the best of their knowledge and belief. Signed this _______________ day of _____________________________ , __________ State Zip Signature of Claimant (Must be signed by Claimant)
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