Cc-Form-93 - Application And Order For Leave To Withdraw As Attorney Of Record
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1WORKERS’ COMPENSATION COMMISSION
THIS SPACE FOR COMMISSION USE ONLY
1915 NORTH STILES AVENUE
CC-FORM-93
OKLAHOMA CITY, OKLAHOMA 73105
Send original and 2 copies to:
Workers’ Compensation Commission
In re claim of:
Full Name of Claimant (Injured Employee)
Claimant’s Social Security Number (LAST 4 DIGITS ONLY)
APPLICATION AND ORDER FOR LEAVE TO WITHDRAW
AS ATTORNEY OF RECORD
XXX-XX-___________________________
Name of Employer (Respondent)
COMMISSION FILE NO.
Date of injury
Employer’s Insurance Carrier, Permit # for Commission Approved Individual Self-Insured or Own
Risk Group, Uninsured
COMES NOW the undersigned Attorney of Record in the above-captioned matter and requests the Commission for leave to withdraw as
Attorney of Record pursuant to Workers’ Compensation Commission Rule 810:10-1-10(c), and in support thereof states:
NO
YES
Please mark the appropriate yes/no response to the left of each numbered question.
________
________
1.
The client has knowledge of this Application To Withdraw as Attorney.
________
________
2.
The client has approved the withdrawal.
________
________
3.
I have made a good faith effort to notify the client and the client cannot be located.
________
________
4.
The case is set for:
Hearing
PHC
Mediation
Date of Proceeding: _________________________ On the Issue(s) ________________________________
_______________________________________________________________________________________
________
________
5.
The case has been heard and is pending for an Order.
HEARING DATE: ________________________ On the Issue(s) of: __________________________________
_______________________________________________________________________________________
________
________
6.
The case is pending on appeal to the :
Commission En Banc
Supreme Court
________
________
7.
An Order awarding Permanent Total Disability has been entered by the Commission.
DATE OF ORDER: _________________________________________________________________________
________
________
8.
An Order awarding Death Benefits has been entered by the Commission.
DATE OF ORDER: _________________________________________________________________________
I declare under PENALTY OF PERJURY that I have examined all statements contained herein, and to the best of my knowledge and
belief, they are true, correct and complete. Any person who commits workers’ compensation fraud, upon conviction, shall be guilty of
a felony punishable by imprisonment, a fine or both.
I HEREBY CERTIFY THAT A COPY HAS BEEN SENT TO:
Signed this _____ day of __________________________,______
Opposing Party
Signature of Requesting Party
Address (Number & Street)
Address (Number & Street)
City
State
Zip Code
City
State
Zip Code
Withdrawing Attorney’s Client
Telephone # of Requesting Party
Address (Number & Street)
City
State
Zip Code
Print or type name of Attorney
OBA #
IT IS THEREFORE ORDERED, for good cause shown, that the above signed attorney is hereby permitted to withdraw as Attorney of Record
from the above captioned case.
BY ORDER OF ____________________________________________________ ____________________________________
Administrative Law Judge
Date of Order
Revised 12-18-14
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