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Proof Of Loss (Death Claim) CC-Form-20 - Oklahoma

Proof Of Loss (Death 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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THIS SPACE FOR COMMISSION USE ON Y CC-FORM-20 Send original to: or er o en a on o i ion and to ll t er ar e o e ord o WORKERS' COMPENSATION COMMISSION 9 5 N TH STILES VENUE KL H M ITY, KL H M 73 05 IN THE MATTER OF THE DEATH OF Full Na e o De ea ed E lo ee (P EASE TYPE OR PRINT) Full Na e o er on Filing roo o Lo PROOF OF LOSS (DEATH CLAIM) MMISSI N FILE N roved Individual Sel -In ured or wn i Grou , Na e o E lo er . E lo er In uran e arrier, er it # or ourt Unin ured De ea ed E lo ee So ial Se urit Nu ber (L ST 4 DIGITS NLY) XXX-XX-_____________________ ST TE F KL H M ) ) SS. UNTY F ___________________________) ( LE SE TY E INT) __________________________________________________, (name of person filing proof of loss) o law ul age, being fir t dul worn on oat , allege and tate : T e affiant i t e ______________________________________________, (rela on o e ease emplo ee) o t e de ea ed e lo ee. T e above na ed de ea ed u tained a o en able a idental injur on or about _____________________________, ___________ w ile in t e e lo o t e e lo er, ro and a a re ult o w i t e de ea ed died on ______________________________________, ____________. tt e e o deat , t e de ea ed wa law ull arried to _______________________________________________________________ (name of spouse) w o e addre i ____________________________________________________________________ and le urviving t e ollowing na ed ildren and de endent : CHILDREN (Li t addi onal ildren on t e ba o t i or .) FULL N ME . ____________________________________________________________ 2. ____________________________________________________________ 3. ____________________________________________________________ 4. ____________________________________________________________ D TE F BI TH ___________________ ___________________ ___________________ ___________________ DD ESS ____________________________________________ ____________________________________________ ____________________________________________ ____________________________________________ DEPENDENTS ( arent , i TU LLY DE ENDENT under t e wor er o en a on law o la o a.) FULL N ME D TE F BI TH DD ESS . ____________________________________________________________ ___________________ 2. ____________________________________________________________ ___________________ 3. ____________________________________________________________ ___________________ 4. ____________________________________________________________ ___________________ ____________________________________________ ____________________________________________ ____________________________________________ ____________________________________________ d tra e r er C ea t 1a Any person or en ty ho ma es any materia a se statement or representa on ho i u y and no ing y omits or concea s any materia in orma on or ho emp oys any de ice scheme or ar ce or ho aids and abets any person or the purpose o : (1) obtaining any bene t or payment ... sha be gui ty o a e ony." er fie r t t r er ea ra d a e t ae ae r eta I affirm I have read this Proof of Loss and de lare under PENALTY OF PERJURY t at all tate ent are true and a urate to t e be t o I er t at on ______________________________________________, ____________, I o o ing art / oun el a noted below. ailed a o o ne e ar nowledge and belie . er fi ate to t e arriage, birt and deat ________________________________________________________________________________________________________________ Signature o Person Comp e ng this Proo o oss DATE I HERE Y CERTIFY THAT A COPY HAS EEN SENT TO: Opposing Party Name o C aimant s A orney i represented OA Address (Number and Street) Address o A orney Zip Code (Inc ude City State and Zip Code) City State Te ephone Signature o C aimant s A orney i any DATE Created 2-1-14 American LegalNet, Inc. www.FormsWorkFlow.com
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