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Oklahoma Form Center -

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Form

Description

CC-form2.pdf Employers' First Notice of Injury
CC-form1a.pdf POSTER - Oklahoma Workers' Compensation Notice and Instruction to Employers and Employees
CC-form1a-sp.pdf POSTER - Oklahoma Workers' Compensation Notice and Instruction to Employers and Employees (Spanish)
CC-form2a.pdf Employer's Intent to Accept or Controvert Claim
CC-form2a-ext.pdf Employer's Application and Authorization for Extension of Time to File CC-FORM-2A (Email submission is not currently available)
CC-notice.pdf Notice to Injured Workers
CC-form3.pdf Employee's First Notice of Accidental Injury and Claim for Compensation. (Mandatory Form Color: Light Blue)
CC-form3a.pdf Claimant's First Notice of Death and Claim for Compensation (Mandatory Form Color:Cream)
CC-form3b.pdf Employee's First Notice of Occupational Disease and Claim for Compensation (Mandatory Form Color: Lilac)
CC-form3c.pdf Claim for Workers' Compensation Discrimination or Retaliation
CC-form3f.pdf Employee's Notice of Claim for Benefits from The Multiple Injury Trust Fund (Mandatory Form Color: Gray)
CC-form4.pdf Report of Compensation Paid
CC-form5.pdf Physician's Report on Release and Restrictions
CC-form7.pdf Designation of Service Agent
CC-form9.pdf Request for Hearing
CC-form10.pdf Answer and Notice of Contested Issues
CC-form-10a.pdf Respondent's Response to Claimant's CC-FORM-A Application for Change of Physician
CC-form10c.pdf Employer's Response to Claim for Workers Compensation Discrimination or Retaliation
CC-form13.pdf Request for Prehearing Conference
CC-form17.pdf Physician Disclosure Statement
CC-certofreadiness.pdf Certificate of Readiness
CC-form20.pdf Proof of Loss (Death Claim)
CC-form36.pdf Application for Certificate of Non Coverage
CC-form40.pdf Request for Review of Proposed Judgment
CC-form-71.pdf Authorization for Attorney Representation
CC-form93.pdf Application and Order for Leave to Withdraw as Attorney of Record
CC-form99.pdf Pauper's Affidavit
CC-form100.pdf Claimant's Application and Order for Dismissal
CC-form211.pdf Request for Review of Adverse Benefit Determination
CC-form300.pdf Request for Proceeding Regarding Arbitration Agreement
CC-form463.pdf Application for Independent Medical Examiner
CC-form626.pdf Medical Case Manager Application
CC-form862.pdf Vocational Rehabilitation Services (VRS) Registry Form
CC-form926.pdf Application for Appointment as Certified Workers' Compensation Mediator
CC-forma.pdf Claimant's Application for Change of Physician and Request for Hearing
CC-forma-order.pdf Order for Change of Treating Physician
CC-formm.pdf Request to Workers' Compensation Commission for Appointment Independent Medical Examiner, Rehabilitation Evaluator, or Medical Case Manager
CC-formv.pdf Verification of Permanent Total Disability
CC-formjp.pdf Joint Petition Settlement
CC-formjp-appendix.pdf Joint Petition Settlement Appendix
CC-cert-to-jp.pdf Certificate to Joint Petition
CC-mediationrequest.pdf Workers' Compensation Commission Mediation Request Form
CC-mediationagreement.pdf Mediation Agreement
CC-reportmediation.pdf Mediation Conference Report
deathclaim.pdf Death Claim Settlement Order
MFDR-form10m.pdf Response to Provider Request for Medical Fee Dispute Resolution
MFDR-form19.pdf Provider Request for Medical Fee Dispute Resolution
Req-WCInfo-ER.pdf Prior Claims Request By Mail With Employer Designation
Req-WCInfo-NonExempt.pdf Prior Claims Request By Mail- Nonexempt Requestor
Req-WCFile-NonExempt.pdf Prior Claims Request - Nonexempt Requestor
Req-WCFile-Exempt.pdf Prior Claims Request - Exempt Requestor
Affidavit_Exempt_Status.pdf Affidavit of Exempt Status under the Workers' Ccompensation Act
subpoena.pdf Subpoena ( Issued from Oklahoma City Office)
subpoena_tulsa.pdf Subpoena- (Issued from Tulsa Office)
SI-Employer.pdf Application for Individual Own Risk Employer Permit
SI-Group.pdf Application for Group Self Insurance Association Permit
SI-BOND.pdf Surety Bond of Self-Insurer of Workers' Compensation (sample form)
SI-LOC.pdf Letter of Credit - Sample Form
SI-TPA.pdf Application for Third-Party Administrator Permit
Tax-Report.pdf Workers' Compensation Premium Tax Report
SubjectLineDetailAuthorization.pdf Subject Line Detail Authorization
CC-copyrequest.pdf Copy Request Form
CC-copiercharge.pdf Copier Charge Account Maintenance Form
form2.pdf Employer's First Notice of Injury, for Dates of Injury Prior to 2/1/2014
form3.pdf Employees First Notice of Accidental Injury and Claim for Compensation. (Mandatory Form Color: Yellow)
form3a.pdf Employees First Notice of Accidental Injury and Claim for Compensation. (Mandatory Form Color: Gold)
form3b.pdf Claimant's First Notice of Death and Claim for Compensation (Mandatory Form Color: Gray)
form3e.pdf Employee's Claim for Benefits for Combined Disabilities against the Last Employer
form3f.pdf Employee's Notice of Claim for Benefits From Multiple Injury Trust Fund (Mandatory Form Color:Tan)
form4.pdf Treating Physician's Report And Notice Of Treatment
form5.pdf Physician's Release and Restrictions
form9.pdf Motion to Set for Trial
form10.pdf Answer and Pretrial Stipulation Offered by Respondent. (Mandatory Form Color: Green)
form10a.pdf Respondent's Response to Claimant's Form A Application For Change of Physician. (Mandatory Form Color: Blue)
form10m.pdf Response to Request for Payment of Charges for Medical or Rehabilitative Services. (Mandatory Form Color: Ivory)
form13.pdf Request for Pre-hearing Conference
form18.pdf Request For Court Administrator Review of Disputed Medical Charges. (Mandatory Form Color: Orchid)
form19.pdf Request for Payment of Charges for Medical or Rehabilitative Services/ Notice of Appeal of Administrative Order.
form20.pdf Proof Of Loss For Spouse And Children. (Mandatory Form Color: Blue)
form93.pdf Application and Order for Leave to Withdraw as Attorney of Record.
form99.pdf Pauper's Affidavit (two-sided form)
form100.pdf Claimant's Application and Order for Dismissal.
forma.pdf Claimant's Application for Accelerated Docket for Change of Physician
forma-order.pdf Order for Change of Treating Physician
cs-appendix.pdf Compromise Settlement Appendix
ccs.pdf Certificate to Compromise Settlement
csd-337.pdf Compromise Settlement - Death Claim
cs-339a.pdf Compromise Settlement
cs-339b.pdf Compromise Settlement - Agreement between Employer and Employee as to Fact with Relation to an Injury and Payment of Compensation
NPT.pdf Request for Nunc Pro Tunc
imereqfrm2.pdf Order for Appointment of Independent Medical Examination
request.pdf Request for Independent Medical Examiner, Rehabilitation Evaluator, or Medical Case Manager
crform.pdf Copy Request Form
osfvend.pdf Vendor Maintenance Form
CECRequest.pdf Prior Claims Request Form and instruction for filling out Request Form
Form926.pdf Application for Appointment as Certified Workers' Compensation Mediator
CECsubpoenaduces.pdf Subpoena Duces Tecum (for the production of documents)
CECsubpoena-standard.pdf Subpoena (for appearance)
CECRequisition.pdf Requisition for Workers' Compensation File - Exempt Requestor
CEC-copiercharge.pdf Copier Charge Account Maintenance Form