Form 3f - Employee'S Notice Of Claim For Benefits From The Multiple Injury Trust Fund
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1THIS SPACE FOR COURT USE ONLY
FORM 3F
COURT OF EXISTING CLAIMS
1915 NORTH STILES, STE 127
Send original to
OKLAHOMA CITY, OK 73105-4918
Court of Existing Claims and 1 copy to
Please check appropriate box
Multiple Injury Trust Fund
I. Original Filing
II. Amends Previously Filed Form 3F (Must
Name of Claimant (injured employee)
clearly state whether amendment is in
addition
to,
or
substitute
for,
prior
information.)
EMPLOYEE’S NOTICE OF CLAIM FOR BENEFITS
MULTIPLE INJURY TRUST FUND
P.O. Box 528801
FROM THE MULTIPLE INJURY TRUST FUND
Oklahoma City, OK 73152
WCC FILE NO.
(Please type or print)
EMPLOYEE NAME (Last, First, Middle)
Social Security # (LAST 4 DIGITS ONLY)
Phone:
(
)
XXX-XX-________________
Mailing Address (include City, State, & Zip)
Date of Birth:
Age:
Sex:
Date of Injury
Date of Order
Percentage of Disability Awarded and Body Part
Court File Number for most recent injury
Rate of weekly compensation for permanent partial disability/permanent
Amount of Compromise Settlement or Other Settlement
partial impairment at the time of the most recent injury
Court File No.
Date of Injury
Date of Order
% of Disability & Body Part
Amount of Compromise
Settlement or Other
Settlement
P
R
I
O
R
Are weekly benefits still being paid on any of the above orders?
YES
NO
If so, when are benefits expected to terminate?
List and describe fully any other pre-existing disability for which no award has been made. (Pre-existing disability means any obvious and apparent disability
resulting from any cause, which disability is obvious and apparent from observation of a person who is not skilled in the medical profession.)
Upon filing this Employee’s Notice of Claim for Benefits from the Multiple
Injury Trust Fund, permission is given to the Administrator of the Court of
Any person who commits workers’ compensation fraud, upon
Existing Claims, the Insurance Commissioner, the Attorney General, a
conviction, shall be guilty of a felony.
District Attorney or their designees to examine all records relating to the
claim, any matter contained in the claim, and any matter relating to the
claim. The permission granted to the above named persons authorizes
them access to medical records pursuant to 76 O.S., §19, including waiver
of any privilege granted by law concerning communications made to a
Name of claimant’s attorney if represented:
physician or health care provider or knowledge obtained by such
Type or Print Name of Attorney:
OBA #
physician or health care provider by personal examination.
I declare under penalty of perjury that I have examined this Notice of
Mailing Address:
Claim for Benefits from the Multiple Injury Trust Fund and all statements
contained herein are true, correct and complete, to the best of my
City:
State:
Zip:
knowledge. I certify a true and correct copy of this Notice of Claim was mailed
to the MULTIPLE INJURY TRUST FUND on the date noted below.
Telephone #:
Signed this __________day of______________________,_______________
(
)
____________________________________________________________
________________________________________________________________
Signature of Attorney for Claimant
Signature of Claimant (must be signed by claimant)
Rev. 06/24/2015
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