Copy Request Form

COPY SUBMIT REQUEST FORM TO OKLAHOMA COURT OF EXISTING CLAIMS REQUEST FORM Rev. 06/24/2015 FOR COURT USE ONLY Oklahoma Court of Existing Claims ATTENTION: Copy Requests 1915 North Stiles, Ste 127 Oklahoma City, OK 73105-4918 FEE FOR FILES PULLED PAID EXEMPT Company Name: ______________________________________ COPIES Attention: _____________________________ Telephone: ( _____ ) _______________ TO BE Address: ______________________________________________________________ RETURNED TO City/State/Zip: ______________________________________________________________ 1. 2. FOR EACH COURT FILE NUMBER YOU MUST: Use a Separate Copy Request Form, and Complete and Sign Part I of this form, if applicable, OR if not applicable, Complete and Sign Part II of this form and Include a $1 Search Fee.1 INQUIRIES General Inquiries . . . Records Dept. (405) 522-8640 Records Management Dept. Supervisor . . . Katrina Stephenson (405) 522-8640 Claimant's Name FORM A FORM 3 Change of Physician Employee's First Notice of Accidental Injury & Claim for Compensation Date of Injury WCC File No. ORDER Entered on ______/______/______ ALL ORDERS ENTRIES OF APPEARANCE SUBSTITUTION OF ATTORNEY ATTORNEY WITHDRAWALS ALL MEDICAL REPORTS FORM 19 FORM 20 Request for Payment of Charges for Medical or Rehabilitative Services - Notice of Appeal of Administrative Order Proof of Loss (Death Claim) FORM 3A Claimant's First Notice of Death & Claim for Compensation FORM 3B Employee's First Notice of Occupational Disease & Claim for Compensation FORM 3F Employee's Claim for Benefits from the Multiple Injury Trust Fund FORM 9 Motion to Set for Trial WITH ATTACHMENTS FORM 10 Answer & Pretrial Stipulation Offered by Respondent WITH ATTACHMENTS FORM 13 Request for Prehearing Conference ENTIRE FILE Files May Contain Duplicate Documents . . . BILLING IS FOR ALL COPIES, INCLUDING DUPLICATES OTHER (Specify) Settlement Agreement (Form CS-337, Form CS-339-A, Form CS-339-B, Other) WITH ATTACHMENTS PART I. STATEMENT OF EXEMPTION: By signing below, I affirm that I meet the requirements of an exemption from the written request and Search Fee requirements of Title 85 O.S. Section 372, as indicated below, and that the information sought is not requested for any non-exempt purpose; provided, however, an employer or personnel service company claiming EXEMPTION #6 ALSO MUST COMPLETE PART II OF THIS FORM. Please circle the number of the exemption that applies: 1. 2. 3. 4. 5. 6. EXEMPTIONS Requests made by a public officer or public employee in the performance of his/her duties on behalf of a governmental entity, or as may be allowed by law; Requests made by an insurer, self-insured employer, third-party claims administrator, or a legal representative thereof, when necessary to process or defend a workers' compensation claim; Requests made by a worker or worker's representative for the worker's claim information; Disclosures made for educational or research purposes, in such a manner that the disclosed information cannot be used to identify any worker who is the subject of a claim; Requests made by a health care or rehabilitation provider, or legal representative thereof, when necessary to process payment for services rendered to a worker; Requests made by an employer or personnel service company where the worker executes a written authorization permitting the search and designating the employer or personnel service company as the worker's representative for that purpose. (The written authorization must be submitted with this form.) Your Signature:____________________________________________________Printed Name:______________________________________________________ Telephone No: (______)_____________ Address: _________________________________________ City: _____________________ State: _____ Zip: _____ PART II. COMPLETE THIS IF EXEMPTION #6 (ABOVE) IS CLAIMED OR IF NONE OF THE OTHER EXEMPTIONS LISTED ABOVE APPLY: By signing below, I declare under PENALTY OF PERJURY that the information sought is not for a purpose in violation of any state or federal law. I understand I am required by law to disclose the person for whom this search request is being made, if different from myself. This search is being made for: (Name and address of person for whom this search is being made, IF OTHER THAN THE UNDERSIGNED. Please PRINT.) Name_______________________________________________________ Full Address ____________________________________________________________ Your Signature:___________________________________________________ Printed Name:________________________________________________________ Telephone No: (______)_____________ Address: _________________________________________ City: _____________________ State: _____ Zip: ______ NOTE Please Return A Copy Of This Copy Request Form And Invoice With Your Check Made Payable To The Court of Existing Claims Invoice No.________________________________ Invoice Date:____________________________ ______________ COPIES @ $1.00 per copy (85 O.S., §370) = $________________________ POSTAGE = $_________________________ 1 Total amount due: $____________________ NOTE: BY LAW, THE $1 SEARCH FEE, IF APPLICABLE, MUST ACCOMPANY THE COPY REQUEST WHEN MADE. American LegalNet, Inc. www.FormsWorkFlow.com