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Employees Notice Of Claim For Benefits From The Multiple Injury Trust Fund CC-Form-3F - Oklahoma

Employees Notice Of Claim For Benefits From The Multiple Injury Trust Fund 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-3F USE FOR SUBSEQUENT INJURY OCCURRING ON OR AFTER FEBRUARY 1, 2014 WORKERS' COMPENSATION COMMISSION 1915 NORTH STILES AVENUE OKLAHOMA CITY, OK 73105 Please check appropriate box I. Original Filing II. Amends Previously Filed CC-Form-3F. (Highlight the change and identify whether it adds to or replaces the prior information.) THIS SPACE FOR COMMISSION USE ONLY Send original to: Workers' Compensation Commission and 1 copy to the Multiple Injury Trust Fund and 1 copy to the Oklahoma State Treasurer Full Name of Claimant (Injured Employee) MULTIPLE INJURY TRUST FUND P.O. Box 528801 Oklahoma City, OK 73152 OKLAHOMA STATE TREASURER 2300 N. Lincoln Boulevard, Room 217, State Capitol Bldg. Oklahoma City, OK 73152 (Please type or print) FULL NAME OF EMPLOYEE (Last, First, Middle) Mailing Address (include City, State, & Zip) Commission File Number for most recent injury Amount of Joint Petition Settlement or Other Settlement Date of Injury EMPLOYEE'S NOTICE OF CLAIM FOR BENEFITS FROM THE MULTIPLE INJURY TRUST FUND COMMISSION FILE NO. Social Security # (LAST 4 DIGITS ONLY) XXX-XX-________________ Phone: ( ) Age: Sex: Date of Birth: Date of Order Percentage of Disability Awarded and Body Part Rate of weekly compensation for permanent partial disability at the time of the most recent injury Commission File No. Date of Injury Date of Order % of Disability & Body Part Amount of Joint Petition Settlement or Other Settlement P R I O R Are weekly benefits still being paid on any of the above orders? YES NO If so, when are benefits expected to terminate? List and describe fully any other pre-existing disability for which no award has been made. (Pre-existing disability means any obvious and apparent disability resulting from any cause, which disability is obvious and apparent from observation of a person who is not skilled in the medical profession.) 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. The undersigned declare under PENALTY OF PERJURY that they have examined this Notice of Claim for Benefits from the Multiple Injury Trust Fund and all statements contained herein are true, correct and complete, to the best of their knowledge and belief. Additionally, the undersigned certify that a true and correct copy of this Notice of Claim was mailed to the MULTIPLE INJURY TRUST FUND and to the OKLAHOMA STATE TREASURER on the date noted below. Signed this __________day of_______________________________ , _____________. City: Telephone #: ( ) Email: Revised 03-23-15 State: Zip: ________________________________________________________________________ Signature of Claimant (Must be signed by Claimant) Name of Claimant's Attorney, if represented: Type or Print Name of Attorney: Mailing Address: OBA # ________________________________________________________________________ Signature of Attorney for Claimant (if any) American LegalNet, Inc. www.FormsWorkFlow.com
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