Cc-Form-4 - Oklahoma - Report Of Compensation Paid/ Suspension Of Payments

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FOR COMMISSION USE ONLY
OKLAHOMA WORKERS’ COMPENSATION COMMISSION
CC-FORM-4
1915 NORTH STILES AVENUE
OKLAHOMA CITY, OKLAHOMA 73105
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(405) 522-3222 r I -S
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(800) 522-8210
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REPORT OF COMPENSATION PAID/SUSPENSION OF PAYMENTS
AMENDED REPORT
Closing Report
Death/PTD Maximum Liability
Report of Payment Suspension
Update Report (
)
Commission File No.
Carrier Claim No.
Full Employee Name (Last, First, MI)
Employee Social Security No. (Last 4 digits only)
Employer Name
City
State
Zip Code
Carrier or Self-Insured Name
Claims O ce Loca on (mailing address)
DISABILITY INFORMATION
Date of Injury
Last Day Employee Worked
Date Employee Able to RTW
Return-to-Work (RTW) Date
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COMPENSATION INFORMATION:
COMPENSATION PAYMENTS MADE:
(9)
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________________________________
(1) TT
______
______
$ ________________________
(10) O
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(2) TP
______
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________________________
(11) H
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(3) PP
______
______
________________________
(12) M
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________________________________
(4) ______
PT
________________________
(13)
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(5) ______
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(14) Fu r Ex
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(6) Lu
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________________________
(15) R
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________________________________
(7)
P
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________________________
(16) O
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)
________________________________
(8) C
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F
________________________
(1 - 16) GRAN TOTAL
________________________________
SUSPENSION OF PAYMENTS OF COMPENSATION
Su
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: _________________________________________________________________
_______________________________________________________________________________________________________________________________________
C
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)
CERTIFICATION
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r PENALTY OF PER URY
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Signature
Printed or Type ri en Name
Title
Date
Created 2-1-14

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