Oklahoma > Workers Comp
Request For Claims File Information-Prior Claims - Oklahoma
| Request For Claims File Information-Prior Claims Form. This is a Oklahoma form and can be used in Workers Comp . |
|
||||||
 Get this form for FREE as a print-only pdf |
|||||||
|
Please return this form to the address listed below along with all appropriate documents and a self addressed stamped envelope. Please note: This request will not be processed if the self-addressed stamped envelope is not provided. Oklahoma Workers' Compensation Court Attn: Records Department 1915 N Stiles Ave Oklahoma City, OK 73105 ------------------------------------------------------------------------------------------------------------------------------------Fold along dotted line. Place in a window envelope so that the address appears. REQUEST FOR CLAIMS FILE INFORMATION/PRIOR CLAIMS Please indicate By Name First Name the TYPE of search you are requesting (please type or print): By Social Security Number (Requires Authorization from holder of Social Security Number as evidenced by signature below) First Name Last Name Last Name I authorize the use of my social security number to search for workers' compensation information as evidenced by my signature: Signature of SS# Holder: Date Social Security #: This search is being made on behalf of the following: Name: _________________________________________________________________ Address : _______________________________________________________________ City: _______________________________ State: _____ Zip Code: ______________ Please indicate your information below (the preparer of this form): I declare under PENALTY OF PURJURY that the information sought hereby is not for a purpose in violation of any state or federal law. I understand that I am required by law to disclose the person for whom this search request is being made, if different from myself. Preparer's Signature Preparer's Printed Name: Telephone # Address: City: State: Zip Code: Rev. 03/2011 This document is considered a public record under Oklahoma state law. American LegalNet, Inc. www.FormsWorkFlow.com
|
|||||||
