Cc-Form-2 - Employer First Notice Of Injury - Workers' Compensation Commission - 2016
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1WORKERS’ COMPENSATION COMMISSION
CC-FORM-2
THIS SPACE FOR COMMISSION USE ONLY
1915 NORTH STILES AVENUE STE 231
Applicable to Injuries /Deaths Occurring On or After 2/1/14
OKLAHOMA CITY, OK 73105
Send original to Workers’ Compensation Commission and
1 copy to Insurance Carrier
EMPLOYER’S FIRST NOTICE OF INJURY
Please type or print. Enter all dates in MM/DD/YY format.
Full Name of Employee - LAST, FIRST, MIDDLE
Employee Email Address
Complete Address
City
State
Zip
Telephone Number
Employee’s Social Security Number (LAST 4 DIGITS ONLY)
XXX-XX-________________________
Date of Birth
Sex
Length of Employment: Years
Months _______
Date of Hire:__________________________________
Average Weekly Wage
Occupation (job description)
Was employment agreement made in Oklahoma?
YES
NO
NOTE: Mediation is available to help resolve certain workers’ compensation disputes. For information, call (405) 522-5308 or In-State Toll Free (855) 291-3612.
Date of accident or last exposure
Time of accident or exposure
Date Employer Notified
Time workday began
o’clock
AM
PM
o’clock
AM
PM
Last date employee worked
Has employee returned to work?
Did the employee die?
YES
NO
If yes, on what date ? __________________________
YES
NO
If yes, on what date ?__________________________________________
OSHA Log Case #
Place of Accident or Occurrence
City:
County:
State:
Injury Resulted from:
Single Incident
Cumulative Trauma
Occupational Disease
Nature of Injury or Illness
Does employee participate in a certified workplace medical plan:
YES
NO
If yes, name of CWMP:
Describe activities when injury occurred with details of how event occurred. Include object or substance which directly injured the employee.
Identify part(s) of body involved in injury or illness
Full Name and address of Treating Physician (please be complete)
Employer’s Insurance Carrier or Own Risk Group
Policy/Self-Insured Number
Name
Phone
Policy Period: From
To
Address
City
State
Zip
Employer’s Name and Complete Address
Name
Federal ID#
Phone #
Address
City
State
Zip
Type of business (Example: manufacturing, food service, construction)
NAICS Number
Type of Ownership:
Private
State Government
County Government
Local Government
Administrative Workers’ Compensation Act, 85A O.S., §6(A)(1)(a): “Any person or entity who makes any material false statement 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 person for the purpose of: (1) obtaining any benefit or payment … shall be guilty of a felony.”
Any person who commits workers’ compensation fraud, upon conviction, shall be guilty of a felony punishable by imprisonment, a fine
or both.
The undersigned hereby declares under PENALTY OF PERJURY that they have
examined this notice and all statements contained herein are true, correct
and complete, to the best of their knowledge. The undersigned certifies this
CC-Form 2 was sent to the Workers’ Compensation Commission and a copy
A CC-Form 2 must be sent to the Workers’ Compensation
thereof to the employer’s insurer on the date noted below:
Commission and to the employer’s workers’ compensation
insurance carrier within 10 days after the date of receipt of
notice or knowledge of death or injury that results in more
Signed
than three days’ absence from work for the injured employee.
Signature of Preparer
PROVIDING THIS FORM TO THE COMMISSION IS NOT
By
EVIDENCE OF ANY FACT STATED IN THE REPORT IN ANY
Name and Title of Preparer (Please Print)
PROCEEDING WITH RESPECT TO THE INJURY OR DEATH ON
ACCOUNT OF WHICH THE REPORT IS MADE.
Telephone Number
Area Code and Number
Date
Revised 2-2-16
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