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Request For Prehearing Conference CC-Form-13 - Oklahoma

Request For Prehearing Conference 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-13 Send original to Workers' Compensation Commission and 1 copy to All Other Parties of Record (Please type or print) In re claim of: Full Name of Claimant (Injured Employee) THIS SPACE FOR COMMISSION USE ONLY WORKERS COMPENSATION COMMISSION 1915 NORTH STILES AVENUE STE 231 OKLAHOMA CITY, OKLAHOMA 73105 Claimant's Social Security Number (LAST 4 DIGITS ONLY) XXX-XX-_________________________ Name of Employer or Respondent REQUEST FOR PREHEARING CONFERENCE COMMISSION FILE NO. Date of Injury Employer's Insurance Carrier, Permit # for Commission Approved Individual Self-Insured or Own Risk Group, Uninsured NOTE: Mediation is available to help resolve certain workers' compensation disputes. For information, call (405) 522-5308 or In-State Toll Free (855) 291-3612. 1. A request is made for the captioned case to be set for Prehearing Conference at the earliest possible date to address the following issue(s): a. Motion to Terminate Temporary Compensation. b. Objection to Termination of Temporary Compensation. c. Motion to Appoint an Independent Medical Examiner. d. Employer Objection to Claimant's Request for Change of Physician. e. Motion to Consolidate. LIST ALL COMMISSION FILE NUMBERS, EXCLUDING THE ONE LISTED ABOVE. _______________ _______________ _______________ _______________ f Motion to Suspend Proceedings or Benefits. g. Motion to Add Additional Parties. Include the name and complete address, including the zip code, of EACH additional party and INSURER, and the alleged DATE OF INJURY. (Use additional sheets if necessary.) A COPY OF THIS MOTION MUST BE MAILED TO EACH ADDITIONAL PARTY AND INSURER LISTED. Additional Party & Address, including City/State/Zip Insurer & Address, including City/State/Zip Alleged Date of Injury ________________________________________ I ________________________________________ I _________________________ ________________________________________ I ________________________________________ I _________________________ ________________________________________ I ________________________________________ I _________________________ h. Mediation Order. (Note: Parties may pursue mediation by mutual agreement without Commission order.) i. Motion to Review Permanent Total Disability Status pursuant to 85A O.S., §45(D). j. Other __________________________________________________________________________________________ (specify). Has an Administrative Law Judge previously been assigned by the Commission to hear all matters relating to the above-captioned case? YES NO ASSIGNED ADMINISTATIVE LAW JUDGE: ______________________________________________________. 2. THE PARTY REQUESTING THIS PREHEARING CONFERENCE HEREBY CERTIFIES THAT THE PARTIES HAVE CONFERRED OR ATTEMPTED TO CONFER IN GOOD FAITH, BUT HAVE REACHED AN IMPASSE AND ARE UNABLE TO RESOLVE THE ISSUE WITHOUT THE COMMISSION'S ASSISTANCE. 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. The undersigned declare under PENALTY OF PERJURY that they have examined all statements contained herein, and to the best of their knowledge and belief, they are true, correct and complete. Signed this ____________day of _________________, __________. I HEREBY CERTIFY THAT A COPY HAS BEEN SENT TO: Opposing Party/Counsel Address (Number and Street) City State Zip Code Signature of Requesting Party Address City State Zip Code Telephone Number of Requesting Party Print or type name of Attorney OBA # Revised 2-2-16 American LegalNet, Inc. www.FormsWorkFlow.com
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