Cc-Form-4 - Report Of Compensation Paid - Oklahoma Workers' Compensation Commission

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FOR COMMISSION USE ONLY

OKLAHOMA WORKERS’ COMPENSATION COMMISSION

CC-FORM-4

1915 NORTH STILES AVENUE STE 231

OKLAHOMA CITY, OKLAHOMA 73105

Send original to:

(405) 522-5308 or In-State Toll Free (855) 291-3612

Workers’ Compensation Commission and 1

copy to Employee or Beneficiaries

REPORT OF COMPENSATION PAID

AMENDED REPORT

Closing Report

Commission File No.

Carrier Claim No.

Full Employee Name (Last, First, MI)

Employee Social Security No. (Last 4 digits only)

Employer Name

City

State

Zip Code

Carrier or Self-Insured Name

Claims Office Location (mailing address)

DISABILITY INFORMATION

Date of Injury

Last Day Employee Worked

Date Employee Able to RTW

Return-to-Work (RTW) Date

Total days worked between injury and date able to RTW: _____________

TTD Rate:_______________

COMPENSATION INFORMATION:

COMPENSATION PAYMENTS MADE:

(9)

Defense Attorney Fees

________________________________

(1) TTD Weeks ______ Days ______

$ ________________________

(10) Other (Compensation Related)

_______ _________________________

(2) TPD Weeks ______ Days ______

________________________

(11) Hospital Expenses

________________________________

(3) PPD Weeks ______ Days ______

________________________

(12) Medical Expenses

________________________________

(4) ______ Weeks PTD

________________________

(13) Drugs, Medicine

________________________________

(5) ______ Weeks for Death

________________________

(14) Funeral Expenses

________________________________

(6) Lump Sum payment

________________________

(15) Rehabilitation

________________________________

(7) Joint Petition Settlement

________________________

(16) Other (Expense Related)

________________________________

(8) Claimant Attorney Fees

________________________

(1 - 16) GRAND TOTAL

________________________________

I certify under PENALTY OF PERJURY that the foregoing is a complete and accurate report according to the records of the insurer pertaining to payments of compensation

and suspensions of payment information. I further certify that a copy of this report or equivalent information has been provided to the employee or beneficiaries.

Signature

Printed or Typewritten Name

Title

Date

Revised 2-2-16