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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 .
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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 Plea e e a ro riate box THIS SPACE OR COMMISSION USE ONLY Send original to: or er Co en a on Co i ion and 1 o to t e M l le In r Tr t nd and 1 o to t e O la o a State Trea rer I. Original iling II. A end Pre io l iled CC- or -3 . (M t learl tate w et er a end ent i in addi on to, or b t te for, rior infor a on.) ll Na e of Clai ant (In red E lo ee) MULTIPLE INJURY TRUST FUND P.O. Box 528801 O la o a Cit , OK 73152 OKLAHOMA STATE TREASURER 2300 N. Lin oln Bo le ard, Roo 217, State Ca itol Bldg. O la o a Cit , OK 73152 (Please type or print) EMPLOYEE'S NOTICE OF CLAIM FOR BENEFITS FROM THE MULTIPLE INJURY TRUST FUND COMMISSION ILE NO. FULL NAME OF EMPLOYEE (La t, ir t, Middle) So ial Se rit # (LAST 4 DIGITS ONLY) XXX-XX-________________ P one: ( ) Mailing Addre (in l de Cit , State, & Zi ) Date of Birt : Age: Sex: Co i ion ile N ber for o t re ent in r Date of In r Date of Order Rate of wee l o o t re ent in r Per entage of Di abilit Awarded and Bod Part A o nt of oint Pe on Se le ent or Ot er Se le ent en a on for er anent ar al di abilit at t e e of t e Co i ion ile No. Date of In r Date of Order % of Di abilit & Bod Part A o nt of oint Pe on Se le ent or Ot er Se le ent P R I O R Are wee l bene t ll being aid on an of t e abo e order YES NO If o, w en are bene t ex e ted to ter inate Li t and de ribe f ll an ot er re-exi ng di abilit for w i no award a been ade. (Pre-exi ng di abilit ean an ob io an a e, w i di abilit i ob io and a arent fro ob er a on of a er on w o i not illed in t e edi al rofe ion.) and a arent di abilit re l ng fro Administra ve Workers' Compensa on Act, A O S , A1a An er on or en t w o a e an aterial fal e tate ent or re re enta on, w o willf ll and nowingl o it or on eal an aterial infor a on, or w o e lo an de i e, e e, or ar e, or w o aid and abet an er on for t e r o e of: (1) obtaining an bene t or a ent ... all be g ilt of a felon ." Any person who commits workers' compensa on fraud, upon convic on, 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 o e o lai or ene ts ro t e l ple n ry r st n and all statements contained herein are true, correct and complete, to the best of their knowledge and belief Addi onally, the undersigned cer fy that a true and correct copy of this o e o lai was mailed to the MULTIPLE INJURY TRUST FUND and to the OKLAHOMA STATE TREASURER on the date noted below Signed t i __________da of_______________________________ , _____________. Cit : State: Zi : Na e of Clai ant A orne , if re re ented: T e or Print Na e of A orne : OBA # Mailing Addre : Tele ( one #: ) ________________________________________________________________________ Signat re of Clai ant (M t be igned b Clai ant) ________________________________________________________________________ Signat re of A orne for Clai ant (if an ) Created 2-1-14 American LegalNet, Inc. www.FormsWorkFlow.com
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