Oklahoma > Workers Comp
Employers First Notice Of Injury 2 - Oklahoma
| Employers First Notice Of Injury Form. This is a Oklahoma form and can be used in Workers Comp . |
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FORM 2 Send original to Workers' Compensation Court and 1 copy to Insurance Carrier Please type or print. Enter all dates in MM/DD/YY format. Full Name of Employee - LAST, FIRST, MIDDLE WORKERS' COMPENSATION COURT 1915 NORTH STILES OKLAHOMA CITY, OK 73105-4918 EMPLOYER'S FIRST NOTICE OF INJURY Employee Email Address THIS SPACE FOR COURT USE ONLY Complete Address City State Zip Telephone Number Social Security Number Date of Birth Sex Length of Employment Years Months Average Weekly Wage Occupation (job description) Was employment agreement made in Oklahoma? YES NO NOTE: Mediation is available to address certain workers' compensation disputes. For information, call (405) 522-8760 or In-State Toll Free (800) 522-8210. Date of accident or last exposure Time of accident or exposure o'clock Last date employee worked Has employee returned to work? YES OSHA Log Case # Date Employer Notified Time workday began o'clock AM PM AM PM Did the employee die? YES NO If yes, on what date NO If yes, on what date Place of Accident or Occurrence City: County: Occupational Disease Does employee participate in a certified workplace medical plan: If yes, name of CWMP: YES State: Injury Resulted from: Nature of Injury or Illness Single Incident Cumulative Trauma NO Describe activities when injury occurred with details of how event occurred. Include object or substance which directly injured the employee. Identify part(s) of body involved in injury or illness Full Name and address of Treating Physician (please be complete) Employer's Insurance Carrier or Own Risk Group Name Address Employer's Name and Complete Address Name Address Federal ID# City Policy/Self-Insured Number Phone City Policy Period--from State Zip to Phone # State Zip Type of business (Example: manufacturing, food service, construction) NAICS Number Type of Ownership: Private State Government County Government Local Government Upon filing this Notice of Injury, permission is given to the Administrator of the Workers' Compensation Court, the Insurance Commissioner, the Attorney General, a District Attorney or their designees to examine all records relating to the notice, any matter contained in the notice, and any matter relating to the notice. Any person receiving temporary disability benefits from an employer or the employer's insurance carrier shall within seven (7) days report in writing to the employer or insurance carrier any change in a material fact or the amount of income the employee is receiving or any change in the employee's employment status, occurring during the period of receipt of such benefits. Any person who commits workers' compensation fraud, upon conviction, shall be guilty of a felony. The undersigned hereby declares under penalty of perjury that they have examined this notice and all statements contained herein are true, correct and complete, to the best of their knowledge. The undersigned certifies this Form 2 was sent to the Workers' Compensation Court and a copy thereof to the employer's insurer on the date noted below: A Form 2 must be filed with the Workers' Compensation Court and sent to the Employer's workers' compensation insurance carrier within 10 days of notice that an employee has suffered an accidental injury which results in lost time beyond the shift, or requires medical attention away from the work site, fatal or otherwise. Form 2s filed with the Workers' Compensation Court are confidential and not subject to public disclosure except as authorized by law. FILING OF THIS FORM IS NOT AN ADMISSION OF LIABILITY OR THAT THE EMPLOYEE HAS PROVIDED PROPER NOTICE OF INJURY. Signed By Telephone Number Date Signature of Preparer Name and Title of Preparer (Please Print) Area Code and Number American LegalNet, Inc. www.FormsWorkFlow.com Rev. 08/11
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