Form 3 - Employee'S First Notice Of Accidental Injury And Claim For Compensation printable pdf download

FORM 3

WORKERS’ COMPENSATION COURT

THIS SPACE FOR COURT USE ONLY

1915 NORTH STILES

Send original and 4 copies to:

OKLAHOMA CITY, OK 73105-4918

Workers’ Compensation Court

Please check appropriate box

Name of Claimant (Injured Employee)

I. Original Filing

II. Amends Previously Filed Form 3. Must

Name of Employer

clearly state whether amendment is in

addition

to,

substitute

for,

prior

information.)

Court Use Only

EMPLOYEE’S FIRST NOTICE OF ACCIDENTAL INJURY AND CLAIM FOR COMPENSATION

NOTE: Mediation is available to address certain workers' compensation disputes.

WCC FILE NO.

For information, call (405) 522-8760 or In-State Toll Free (800) 522-8210.

(Please type or print)

Phone:

EMPLOYEE NAME (Last, First, Middle):

Social Security #:

(

)

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 Accident, or as applicable, Date of Termination

Injury resulted from:

Time Injury Occurred

From Employment if a Cumulative Trauma Injury:





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

Benefits?

30 months of the filing of this Notice of Accidental Injury and 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 “Form 3F” with the Workers’ Compensation Court.

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:

Any person receiving temporary disability benefits from an employer or the employer's insurance carrier shall within seven (7) days report in writing

to the employer or insurance carrier any change in a material fact or the amount of income the employee is receiving or any change in the

employee’s employment status, occurring during the period of receipt of such benefits.

Any person who commits workers’ compensation fraud, upon conviction, shall be guilty of a felony.

Upon filing this Notice of Accidental Injury And Claim For Compensation,

permission is given to the Administrator of the Workers' Compensation

Court, the Insurance Commissioner, the Attorney General, a District

Name of claimant’s attorney if represented:

Attorney or their designees to examine all records relating to the notice, any

Type or Print Name of Attorney:

OBA#

matter contained in the notice, and any matter relating to the notice. The

permission granted to the above persons authorizes them access to medical

Mailing Address:

records pursuant to 76 O.S., §19, including waiver of any privilege granted

by law concerning communications made to a physician or health care

provider or knowledge obtained by such physician or health care provider

City

State

Zip

by personal examination. This form is not intended for use as a medical

authorization.

Nothing shall be construed to waive, limit or impair any

evidentiary privilege recognized by law.

Telephone #:

(

)

I declare under penalty of perjury that I have examined this notice and claim

for compensation and all statements contained herein are true, correct and

complete to the best of my knowledge and belief.

Signed this _______________ day of _________________________ , ________

Signature of Attorney for Claimant

Signature of Claimant (must be signed by claimant)

08/26/11

Form 3 - Employee'S First Notice Of Accidental Injury And Claim For Compensation

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