Cc-Form-71 - State Of Oklahoma - Authorization For Attorney Representation
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1WORKERS’ COMPENSATION COMMISSION
CC-FORM-71
THIS SPACE FOR COMMISSION USE ONLY
1915 NORTH STILES AVENUE
OKLAHOMA CITY, OKLAHOMA 73105
Attach to Entry of Appearance filed by Attorney
Representative
In re claim of:
□
□
□
Full Name of
Injured Employee
Beneficiary/Guardian in Death Claim
Provider
Full Name of Deceased Employee if Death Claim
Social Security Number of Injured Employee or, if Death Claim, Deceased Employee (LAST 4
DIGITS ONLY)
Name of Employer (Respondent)
Commission File Number
Employer’s Insurance Carrier, Permit # for Commission Approved Individual Self-Insured or
Date of Injury
Group Self-Insurance Association
AUTHORIZATION FOR ATTORNEY REPRESENTATION
[Attach to entry of appearance as provided in Commission Rule 810:10-1-10(b).]
(name of party) designates the following attorney or law firm to serve
as □ my □ our authorized representative in the above referenced matter, to receive all notices in □ my □ our behalf and to provide
services in this matter, including the presentation of evidence relating to the claim, unless and until this authorization is terminated or
withdrawn by further written notices or upon an order of withdrawal pursuant to the filing of a CC-Form-93 (Application and Order for
Leave to Withdraw as Attorney of Record):
REPRESENTATIVE INFORMATION
(Please type or print.)
Full Name of Representative (Last, First, MI)
OBA #
Mailing Address
City
State
Zip
Email Address
Telephone Number (Area Code, Number and Extension )
FAX Number
Firm Name
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.
NOTE: Both the designated representative and the client must sign and date this Authorization for Attorney Representation.
By signing below the □ injured employee □ beneficiary/guardian in death claim □ provider (if an individual, or the authorized agent of
the provider) □authorized agent of the respondent employer/carrier, who is making this designation, acknowledges the representative
indicated above will represent them in the above referenced matter. By signing below, the representative accepts this designation.
The undersigned declare under PENALTY OF PERJURY that they have examined all statements contained herein, and to the best of their
knowledge and belief, they are true, correct and complete.
□
□
Date Signed
Party’s Signature
Respondent Employer/Insurer
Injured Employee
□
□
Beneficiary/Guardian in Death Claim
Provider
Print or Type Name of Party Signing
Representative’s Signature
Date Signed
Print or Type Name of Representative
Revised 12-18-14
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