Designation Of Service Agent {CC-Form-7}

This space for Commission Use only WORKERS' COMPENSATION COMMISSION 1915 NORTH STILES AVE OKLAHOMA CITY, OK 73105 405-522-3222 CC-FORM-7 DESIGNATION OF SERVICE AGENT Any person who commits workers' compensation fraud, upon conviction, shall be guilty of a felony punishable by imprisonment, a fine, or both. The following entities must designate a single agent for service of notice by filing this Designation of Service Agent form with the Commission: insurance carriers; individual own-risk employers; group self-insurance associations; and qualified employers. Consistent with Workers' Compensation Commission Rule 810:10-1-11, once a claim for compensation (CC-Form-3, CCForm-3A or CC-Form-3B) is filed, the Commission will send all notices and correspondence to the designated agent, until an entry of appearance or a notice of substitution of attorney is filed as provided in Commission Rules 810:10-1-10 or -11. The following information is required and must be amended whenever a change of service agent is made. Please check ( Carrier Individual Own Risk Employer Group Self-Insurance Association Qualified Employer _______________________________________________________ Entity Name _______________________________________________________ Name of contact person ) the appropriate box below: (If this service agent designation applies to the entity's subsidiaries, attach a list of the applicable subsidiaries and/or affiliates, including addresses.) ____________________________________ Entity Phone Number ___________________________________ Contact Email ______________________________________________________________________________________________ Home Office Mailing Address City State Zip ______________________________________________________________________________________________ Street Address (if different): City State Zip Designated Service Agent Information: _______________________________________________________ Agent Name _______________________________________________________ Name of contact person if the service agent is a business ____________________________________ Agent Phone Number ___________________________________ Agent Email ______________________________________________________________________________________________ Home Office Mailing Address City State Zip ______________________________________________________________________________________________ Street Address (if different): City State Zip ____________________________________________ __________________________________________________ Signature of Entity Representative Printed Name of Entity Representative ____________________________________________ ___________________________________________________ Date Signed Title of Entity Representative Revised 09/15 American LegalNet, Inc. www.FormsWorkFlow.com