Cc-Form-V - Verification Of Permanent Total Disability

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FOR COMMISSION USE ONLY
CC-FORM-V
OKLAHOMA WORKERS’ COMPENSATION COMMISSION
1915 NORTH STILES AVENUE STE 231
OKLAHOMA CITY, OKLAHOMA 73105
(405) 522-5308 or In-State Toll Free (855) 291-3612
VERIFICATION OF PERMANENT TOTAL DISABILITY
(Please print legibly in ink.)
Full Name of
Employee:
_________________________________________________________________________________________________________
Address
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
City
State
Zip
Commission File No.: ____________________________________
Name of Employer: _______________________________________
Employee’s Social Security No. (Last 4 digits only.): XXX-XX-_________________
Date of Injury: ______________________
I, ______________________________________, do hereby certify and affirm under PENALTY OF PERJURY that I am permanently
and totally disabled due to my work-related condition and not capable of gainful employment. Also, I am not presently, nor have I
been, gainfully employed since I became permanently and totally disabled. I further certify that a copy hereof was sent to the
insurance carrier or self-insured employer on the date and at the address noted below.
Insurance Carrier/Self-Insured Employer/Counsel
Address (Number & Street)
City
State
Zip Code
Dated this ________________day of________________________________________________, 2_________.
______________________________________________
Signature
State of __________________________
County of _________________________
SUBSCRIBED AND SWORN TO before me, a Notary Public, on this _____________ day of _________________________________,
2___________.
__________________________________________________
NOTARY PUBLIC
My Commission Expires:
_____________________________________
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.
Revised 2-2-16

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