Cc-Form-3 - Employee'S First Notice Of Claim For Compensation

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CC-FORM-3

WORKERS’ COMPENSATION COMMISSION

THIS SPACE FOR COMMISSION USE ONLY

1915 NORTH STILES AVENUE STE 231

USE FOR ACCIDENTAL INJURY OR CUMULATIVE TRAUMA

OKLAHOMA CITY, OK 73105

OCCURRING ON OR AFTER FEBRUARY 1, 2014

Send original and 4 copies to:

Workers’ Compensation Commission

Please check appropriate box

Full Name of Claimant (Injured Employee)

I. Original Filing

II. Amends Previously Filed CC-Form-3.

Name of Employer

(Highlight the change and identify

whether it adds to or replaces the

prior information.)

Commission Use Only

EMPLOYEE’S FIRST NOTICE OF CLAIM FOR COMPENSATION

NOTE: Mediation is available to help resolve certain workers' compensation disputes. For

COMMISSION FILE NO.

information, call (405) 522-5308 or In-State Toll Free (855) 291-3612.

(Please type or print)

FULL NAME OF EMPLOYEE (Last, First, Middle):

Social Security Number (LAST 4 DIGITS ONLY):

Phone:

(

)

XXX-XX-_______________________________

Mailing Address (include City, State & Zip):

Date of Birth:

Age:

Sex:

Occupation:

Was your employment agreement in

Avg. Weekly Wage:

Length of Employment: Years______ Months_______





Oklahoma? YES

Date of Hire:

Date of Accident/Injury

Injury resulted from:

Time Injury Occurred





Single Incident

Cumulative Trauma

__________________

Describe parts of the body injured or affected

Place of Injury: City/County/State

What is the nature of the Injury or Illness:

Describe with details how the injury occurred. Include object or substance which directly injured you:

Have you filed a claim for Social Security Disability Insurance

Are you eligible for Medicare Benefits or will you become eligible for Medicare Benefits within 30

Benefits?

months of the filing of this Notice of Claim for Compensation?









YES

Are you a previously impaired person due to a prior workers’ compensation injury or obvious and apparent pre-existing disability? _______ If “YES”, you

may be entitled to benefits for combined disabilities against the Multiple Injury Trust Fund. A claim against the Multiple Injury Trust Fund may be

commenced by filing a “CC-Form-3F” with the Workers’ Compensation Commission.

Treating Physician (full name):

Address:

City:

State:

Zip:

Employer:

Employer’s FEI # (Federal ID Number):

Telephone:

Complete Mailing Address:

City:

State:

Zip:

Complete Street Address (if different from above):

City:

State:

Zip:

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.

CLAIM INFORMATION (Please Print)

Is this a claim for initial benefits (i.e. no benefits, either medical or indemnity, have been received)?

□ YES □ NO

Is this a claim for additional benefits (e.g. additional temporary total disability, additional medical)?

□ YES □ NO

_____________________________________________________________________________________________________________________________

List person or entity (with address, phone number) which has paid benefits under a group health, disability or loss of income policy for the injury reported

on this form:___________________________________________________________________________________________________________________

Name of claimant’s attorney if represented:

The undersigned declare under PENALTY OF PERJURY that they have examined

this Employee’s First Notice of Claim for Compensation, and all statements

Type or Print Name of Attorney:

OBA#

contained herein are true, correct and complete, to the best of their

knowledge and belief.

Mailing Address:

Signed this ______ day of __________________________________ , ________.

City

State