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Employers Intent To Accept Or Controvert Claim CC-Form-2A - Oklahoma

Employers Intent To Accept Or Controvert Claim 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-2A Send original to: Workers' Compensation Commission and 1 copy to Employee or Beneficiaries, or to the attorney therefor, if any is known FOR COMMISSION USE ONLY OKLAHOMA WORKERS' COMPENSATION COMMISSION 1915 NORTH STILES AVENUE STE 231 OKLAHOMA CITY, OKLAHOMA 73105 (405) 522-5308 or In-State Toll Free (855) 291-3612 EMPLOYER'S INTENT TO CONTROVERT CLAIM Initial Filing Commission File No. if any Amended Filing Carrier Claim No. Full Employee Name (Last, First, MI) Employee Social Security No. (Last 4 digits only) XXX-XX-_________________ Employer Name Federal Employer ID No. Address City State Zip Code Carrier or Self-Insured Name Claims Office Name, Address, and Phone Is this a medical only claim? Yes No Is this a PPD-Only Claim? Yes No COMPENSATION (if not applicable, skip to next section) Date of First Comp. Check Dates Covered by First Check Body Part Injured First Day of Disability Average Weekly Wage Weekly TTD Comp. Rate Was Disability Continuous During the First 4 Days? Yes Date Indemnity Triggered No STATEMENT OF POSITION Date of injury or death: _______________ City, State of Injury: _________________________________ Parts of the body injured or affected ___________ ___________________________________________ Nature of the Injury or Illness___________________________________________________________ ______________________________________________________________________________________________________________________________ State your position. If controverting, state the grounds therefor (attach additional pages if needed): ___________________________________________ ______________________________________________________________________________________________________________________________ ______________________________________________________________________________________________________________________________ ______________________________________________________________________________________________________________________________ DEATH CASE DATA List all Dependents below: (If more space is needed, attach supplemental sheet) Attach Death Certificate of Deceased Employee and Birth Certificates for Dependent Children Name of Dependent Date of Birth If no Dependents, check here: Relationship to Deceased Weekly Benefit Amount CERTIFICATION I certify under PENALTY OF PERJURY that the foregoing is a complete and accurate report according to the records of the insurer pertaining to first payment, controversion and beneficiary information. I further certify that a copy of this report has been provided to the employee or beneficiaries., or to the attorney therefor, if any is known. Signature Printed or Typewritten Name Title:___________________________________ Phone:__________________________________ If the employer/insurer is represented by an attorney, that legal representative must sign below pursuant to 85A O.S., § 83. Name and Address of Attorney, including OBA # OBA # Date Signature Revised 1-14-16 American LegalNet, Inc. www.FormsWorkFlow.com CC-Form-2A (Employer's Intent to Controvert Claim) Questions about the CC-Form-2A, or general information or assistance on completing or filing a CC-Form-2A, may be directed to the Workers' Compensation Commission Counselor Division, (405) 522-5308 or In-State Toll Free (855) 291-3612. Administrative Workers' Compensation Act, 85A O.S., §6(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. American LegalNet, Inc. www.FormsWorkFlow.com
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