Fillable Cc-Form-10 - Answer And Notice Of Contested Issues printable pdf download

THIS SPACE FOR COMMISSION USE ONLY

CC-FORM-10

WORKERS’ COMPENSATION COMMISSION

1915 NORTH STILES AVENUE STE 231

Send original to:

OKLAHOMA CITY, OKLAHOMA 73105

Workers’ Compensation Commission and 1 copy

to Claimant or the Claimant’s Attorney of

Record, if any

In re claim of:

Full Name of Injured Employee (Claimant)

Claimant’s Social Security Number (LAST 4 DIGITS ONLY)

XXX-XX-_____________________

ANSWER AND NOTICE OF CONTESTED ISSUES

COMMISSION FILE NO.

Name of Employer (Respondent)

Date of Injury

Employer’s Insurance Carrier, Permit # for Commission Approved Individual Self-Insured or

Own Risk Group, Uninsured

NOTE: Mediation is available to help resolve certain workers’ compensation disputes. For information, call (405) 522-5308 or In-State Toll Free (855) 291-3612.

YES

(Please Type or Print)

________ ________

1. Was claimant at the time of the alleged injury, an employee of the respondent named above?

________ ________

2. Was claimant covered by the Administrative Workers’ Compensation Act, Title 85A of the Oklahoma Statutes?

________ ________

3. Did claimant sustain an accidental injury, cumulative trauma or suffer an occupational disease or illness arising out of and in

the course of the employment?

________ ________

4. Has claimant filed a claim for compensation (i.e. a CC-Form-3 or CC-Form-3B) within the statutory period of time?

________ ________

5. Did respondent, at the time of the alleged injury, have an own-risk permit or a compensation insurance policy with the carrier

named above?

________ ________

6. Did claimant timely notify respondent of the injury?

________ ________

7. Has claimant been provided medical treatment?

________ ________

8. Has respondent commenced payment of temporary total disability payments to claimant?

Temporary total disability has been paid to claimant from ________________________ to ______________________ for a

total of _______________________ weeks in the total sum of $______________________________ .

________ ________

9. Has respondent selected a treating physician? Name of treating physician: _________________________________________ .

(ALL DEPOSITIONS OF MEDICAL EXPERTS SHALL BE COMPLETED PRIOR TO THE HEARING BEFORE THE ADMINISTRATIVE LAW JUDGE)

________ ________

10. Is rate an issue? Claimant’s compensation rate: TTD __________________ PPD________________.

11. State all affirmative defenses: ______________________________________________________________________________________________

________________________________________________________________________________________________________________________

12. List the names of all witnesses who may be called by respondent at hearing:

_______________________________________________________

________________________________________________________________________________________________________________________

13. List all exhibits to be introduced at hearing: ___________________________________________________________________________________

________________________________________________________________________________________________________________________

14. Respondent hereby certifies that a copy of the medical report written by Dr. _________________________________________________, and dated

__________________________________________, was mailed, together with a copy of this ANSWER AND NOTICE, to the Opposing Party/Counsel.

Refer to Commission rules on exchange of exhibits. DO NOT attach a copy of the medical report when filing the CC-Form-10 with the Commission.

(LIST ON A SEPARATE SHEET, ADDITIONAL WITNESSES, EXHIBITS AND MEDICAL EVIDENCE)

If compensability of a claim is contested, the respondent shall complete discovery and secure a medical evaluation of the claimant within sixty (60) days of the

claimant’s filing of a claim for compensation. 85A O.S., §111(C).

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.

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.

Signed this __________day of__________________________________,____________.

Signature of □ Respondent □ Insurer □ Counsel for Respondent/Insurer

THE RESPONDENT/INSURER HEREBY CERTIFY THAT A COPY HAS BEEN

SENT TO:

Opposing Party/Counsel