Joint Petition Settlement Appendix {Form-JP-Appendix}

FORM JP-APPENDIX JOINT PETITION SETTLEMENT APPENDIX 1915 NORTH STILES AVENUE STE 231 OKLAHOMA CITY, OK 73105 Full Name of Injured Employee XXX X Name of Employer -Insured or Own Risk Group, Uninsured Commission File Number Date of Injury Use and attach to a CC-Joint Petition ONLY IF the Joint Petition Settlement seeks to settle and determine SOME, BUT NOT ALL, n. NOTE: The original and five (5) copies of the Joint Petition Settlement with Appendix attached are required when the settlement order is submitted to In re Claim of: (Please type or Print ALL information legibly in ink.) By signing below, each party affirms that they have read and understand the provisions of this JOINT PETITION SETTLEMENT APPENDIX, declares under penalty of perjury that all statements are true and accurate to the best of their knowledge and belief, and understands that the Joint Petition olved. t 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 a fine or both. Name of Claimant Name of Respondent X Signature of Claimant DATE Name of Insurance Carrier or Own Risk Group Address of Claimant Type or Print Name of Respondent/Insurer Attorney OBA# X nature of Respondent/Insurer Attorney DATE X THIS SPACE FOR COMMISSION USE ONLY American LegalNet, Inc. www.FormsWorkFlow.com