Form 9 - Claim Form
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1COURT OF EXISTING CLAIMS
FORM 9
THIS SPACE FOR COURT USE ONLY
1915 NORTH STILES, STE 127
Send original to
OKLAHOMA CITY, OKLAHOMA 73105-4918
Court of Existing Claims and 1 copy to
Each Opposing Party/Counsel
In re claim of:
Full Name of Claimant (Injured Employee)
Claimant’s Social Security Number (LAST 4 DIGITS ONLY)
XXX-XX-________________________
MOTION TO SET FOR TRIAL
Name of Employer (Respondent)
WCC FILE NO.
Employer’s Insurance Carrier, Permit # for Court Approved Individual Self-Insured or
Date of Injury
Group Self-Insurance Association
NOTE: Mediation is available to address certain workers’ compensation disputes. For information, call (918) 581-2714.
(Please Type or Print)
1.
Issues to be tried: (Circle all applicable issues below.)
a.
Temporary Total Disability from ________________________ to _______________________________.
b.
Medical Treatment from _____________________________ to ________________________________.
c.
Permanent Partial Disability/Permanent Partial Impairment.
d.
Permanent Total Disability.
e.
Motion to Reopen on Change of Condition. Has the Reopen Fee been paid?
YES
NO
f.
Change of Physician for a worker covered by a Certified Workplace Medical Plan (CWMP). (Note: File a Form A to set a
request for Change of Physician when there is no CWMP.)
g.
Change of Case Manager for a worker not covered by Certified Workplace Medical Plan (CWMP).
h.
Liability of Multiple Injury Trust Fund.
i.
Rate:
TTD____________________PPD/PPI____________________AWW_________________.
j.
Death Benefits.
k.
Appeal from Form 18 Order.
l.
Form 19 (Request For Payment of Health or Rehabilitation Services). Was the Form 19 filed previously?
YES
NO
m. Other (SPECIFY)_____________________________________________________________________________________.
(ALL DEPOSITIONS OF MEDICAL EXPERTS SHALL BE COMPLETED PRIOR TO TRIAL.)
2.
List the names of all witnesses who may be called at trial:________________________________________________________________
______________________________________________________________________________________________________________
3.
List all exhibits to be introduced at trial: ______________________________________________________________________________
______________________________________________________________________________________________________________
4.
Requestor hereby certifies that a copy of the medical report written by Dr. _______________________and dated ________________ was
mailed, together with this motion, to Opposing Party/Counsel. (Refer to Court rules regarding the exchange of exhibits.) Do NOT attach a
copy of the medical report when filing the Form 9 with the Court of Existing Claims.
I declare under penalty of perjury that I have examined this motion and 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.
Signed this____________day of__________________________,___________.
I HEREBY CERTIFY THAT A COPY HAS BEEN SENT TO:
Opposing Party/Counsel
Signature of Requesting Party
claimant
resp.
med/rehab provider
Address (Number & Street)
Address (Number & Street)
City
State
Zip Code
City
State
Zip Code
Telephone # of Requesting Party
Print or type name of Attorney
OBA #
Rev. 06/24/2015
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