Fillable Cc-Form-20 - Proof Of Loss (Death Claim) printable pdf download

THIS SPACE FOR COMMISSION USE ONLY

WORKERS’ COMPENSATION COMMISSION

CC-FORM-20

1915 NORTH STILES AVENUE STE 231

Send original to:

OKLAHOMA CITY, OKLAHOMA 73105

Workers’ Compensation Commission and 1 copy

to All Other Parties of Record

IN THE MATTER OF THE DEATH OF

(PLEASE TYPE OR PRINT)

Full Name of Deceased Employee

Full Name of Person Filing Proof of Loss

PROOF OF LOSS (DEATH CLAIM)

Name of Employer

COMMISSION FILE NO

Employer’s Insurance Carrier, Permit # for Court Approved Individual Self-Insured or Own Risk Group,

Deceased Employee’s Social Security Number (LAST 4 DIGITS ONLY)

Uninsured

XXX-XX-_____________________

STATE OF OKLAHOMA

)

) SS.

COUNTY OF ___________________________)

(PLEASE TYPE OR PRINT)

__________________________________________________, (name of person filing proof of loss) of lawful age, being first duly sworn on oath, alleges and states:

The affiant is the ______________________________________________, (relation to deceased employee) of the deceased employee.

The above named deceased sustained a compensable accidental injury on or about _____________________________, ___________ while in the employ of the

employer, from and as a result of which the deceased died on ______________________________________, ____________.

At the time of death, the deceased was lawfully married to _______________________________________________________________ (name of spouse) whose

address is ____________________________________________________________________ and left surviving the following named children and dependents:

CHILDREN (List additional children on the back of this form.)

FULL NAME

DATE OF BIRTH

ADDRESS

1. ____________________________________________________________

___________________

____________________________________________

2. ____________________________________________________________

___________________

____________________________________________

3. ____________________________________________________________

___________________

____________________________________________

4. ____________________________________________________________

___________________

____________________________________________

DEPENDENTS (Parents, if ACTUALLY DEPENDENT under the workers’ compensation laws of Oklahoma.)

FULL NAME

DATE OF BIRTH

ADDRESS

1. ____________________________________________________________

___________________

____________________________________________

2. ____________________________________________________________

___________________

____________________________________________

3. ____________________________________________________________

___________________

____________________________________________

4. ____________________________________________________________

___________________

____________________________________________

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.

I affirm I have read this Proof of Loss and declare under PENALTY OF PERJURY that all statements are true and accurate to the best of my knowledge and belief.

I certify that on ______________________________________________, ____________, I mailed a copy of necessary marriage, birth and death certificates to the

opposing party/counsel as noted below. NOTE: A certified copy of each of these documents, and other documents necessary to establish actual dependency as defined

by law, must be offered at the time of hearing or settlement.

________________________________________________________________________________________________________________

Signature of Person Completing this Proof of Loss

DATE

I HEREBY CERTIFY THAT A COPY HAS BEEN SENT TO:

Opposing Party

Name of Claimant’s Attorney, if represented

OBA #

Address (Number and Street)

Address of Attorney

(Include City, State and Zip Code)

City