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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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FOR COMMISSION USE ONLY CC-FORM-2A Send original to: or ers Com ensa on Commission and 1 co y to Em loyee or Beneficiaries OKLAHOMA WORKERS' COMPENSATION COMMISSION 1915 NORTH STILES AVENUE OKLAHOMA CITY, OKLAHOMA 73105 (405) 522-3222 or In-State Toll Free (800) 522-8210 EMPLOYER'S INTENT TO ACCEPT OR 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 Con nuous 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 posi on. If controver ng, state the grounds therefor (a ach addi onal pages if needed) ___________________________________________ ______________________________________________________________________________________________________________________________ ______________________________________________________________________________________________________________________________ ______________________________________________________________________________________________________________________________ DEATH CASE DATA List all De endents below: If no De endents, chec here: Name of Dependent Date of Birth Rela onship to Deceased Weekly Benefit Amount CERTIFICATION I cer fy under PENALTY OF PER URY that the foregoing is a com lete and accurate re ort according to the records of the insurer ertaining to first ayment, controversion and beneficiary informa on I further cer fy that a co y of this re ort has been rovided to the em loyee or beneficiaries Signature Printed or Type ri en Name Title:___________________________________ Date Phone:__________________________________ If the em loyer insurer is re resented by an a orney, that legal re resenta ve must sign below ursuant to 85A O S , 83 Name and Address of A orney, including OBA OBA Signature Created 2-1-14 American LegalNet, Inc. www.FormsWorkFlow.com CC-Form-2A (Employer's Intent to Accept or Controvert Claim) A form used to acce t a case and re ort ayment or to controvert The CC-Form-2A also is used to amend osi ons ta en earlier Help With CC-Form-2A 1 The first ayment of com ensa on is due by the 15th day a er the em loyer has no ce of the injury or death (See or ers Com ensa on Commission Rule 810:2-1-5) 2 The Commission is no fied u on ma ing the first ayment (85A O S , 92) 3 A controversion no ce is due on or before the 15th day a er no ce of the death or alleged injury (85A O S , 86) 4 Therefore, the CC-Form-2A is required in all cases by the 15th day from: (a) the day of disability, or (b) the day the em loyer is aware of the alleged incident, whichever date is later The follo ing are required fields on the CC-Form-2A 5 A mar in either the Ini al Filing Bo or Amended Filing Bo 6 The Commission File Number, if any; your com any's file number for this case; the em loyee s full name; the em loyee s Social Security Number (last 4 digits only); the em loyer s name; the carrier or self-insured s name; date of injury or death; city, state of injury; arts of body injured or affected; nature of injury or illness; and statement of osi on (e g that you are aying all medical and TTD benefits due , that you have acce ted the claim as com ensable and are aying all a ro riate benefits ; that you are controver ng the claim because [state your reason(s)] , etc ) Be sure to bear in mind 7 If res ondents need addi onal me for inves ga on, an e tension request must be sent to the Commission before the CC-Form-2A deadline Using the CC-Form-2A to re ort that the res ondent needs more me is invalid 8 If a claim file is o ened at the Commission based on the filing of a claim for com ensa on (CC-Form-3, CC-Form -3A, CC-Form-3B), a CC-Form-2A is required, even if the case u on inves ga on is determined to be a medical only 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) 522-8760 or In-State Toll Free (800) 522-8210. Administra ve Workers' Compensa on Act, A O.S., (A)(1)(a) Any erson or en ty who ma es any material false statement or re resenta on, who willfully and nowingly omits or conceals any material informa on, or who em loys any device, scheme, or ar fice, or who aids and abets any erson for the ur ose of: (1) obtaining any benefit or ayment ... shall be guilty of a felony Any erson who commits wor ers com ensa on fraud, u on convic on, shall be guilty of a felony unishable by im risonment, a fine or both American LegalNet, Inc. www.FormsWorkFlow.com
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