Cc-Form-13 - Request For Prehearing Conference

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CC-FORM-13
THIS SPACE FOR COMMISSION USE ONLY
WORKERS COMPENSATION COMMISSION
1915 NORTH STILES AVENUE
Send original to
Workers’ Compensation Commission and 1 copy
OKLAHOMA CITY, OKLAHOMA 73105
to All Other Parties of Record
(Please type or print)
In re claim of:
Full Name of Claimant (Injured Employee)
Claimant’s Social Security Number (LAST 4 DIGITS ONLY)
REQUEST FOR PREHEARING CONFERENCE
XXX-XX-_________________________
Name of Employer or Respondent
COMMISSION FILE NO.
Employer’s Insurance Carrier, Permit # for Commission Approved Individual Self-Insured or Own Risk
Date of Injury
Group, Uninsured
NOTE: Mediation is available to help resolve certain workers’ compensation disputes. For information, call (405) 522-5308 or In-State Toll Free (855) 291-3612.
1. A request is made for the captioned case to be set for Prehearing Conference at the earliest possible date to address the following
issue(s):
a. Motion to Terminate Temporary Compensation.
b. Objection to Termination of Temporary Compensation.
c. Motion to Appoint an Independent Medical Examiner.
d. Employer Objection to Claimant’s Request for Change of Physician.
e. Motion to Consolidate. LIST ALL COMMISSION FILE NUMBERS, EXCLUDING THE ONE LISTED ABOVE.
_______________
_______________
_______________
_______________
f
Motion to Suspend Proceedings or Benefits.
g. Motion to Add Additional Parties. Include the name and complete address, including the zip code, of EACH additional party
and INSURER, and the alleged DATE OF INJURY. (Use additional sheets if necessary.) A COPY OF THIS MOTION MUST BE
MAILED TO EACH ADDITIONAL PARTY AND INSURER LISTED.
Additional Party & Address, including City/State/Zip
Insurer & Address, including City/State/Zip
Alleged Date of Injury
________________________________________ I ________________________________________ I _________________________
________________________________________ I ________________________________________ I _________________________
________________________________________ I ________________________________________ I _________________________
h. Mediation Order. (Note: Contact the Counselor Division directly to pursue mediation by mutual agreement without Commission
order.)
i. Motion to Review Permanent Total Disability Status pursuant to 85A O.S., §45(D).
j. Other __________________________________________________________________________________________ (specify).
2. Has an Administrative Law Judge previously been assigned by the Commission to hear all matters relating to the above-captioned case?
YES
NO
ASSIGNED ADMINISTATIVE LAW JUDGE: ______________________________________________________.
THE PARTY REQUESTING THIS PREHEARING CONFERENCE HEREBY CERTIFIES THAT THE PARTIES HAVE CONFERRED OR ATTEMPTED TO
CONFER IN GOOD FAITH, BUT HAVE REACHED AN IMPASSE AND ARE UNABLE TO RESOLVE THE ISSUE WITHOUT THE COMMISSION’S
ASSISTANCE.
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.
The undersigned declare under PENALTY OF PERJURY that they have examined all statements contained herein, and to the best of their knowledge and
belief, they are true, correct and complete.
Signed this ____________day of _________________,
__________.
Signature of Requesting Party
I HEREBY CERTIFY THAT A COPY HAS BEEN SENT TO:
Opposing Party/Counsel
Address
Address (Number and Street)
City
State
Zip Code
Telephone Number of Requesting Party
City
State
Zip Code
Print or type name of Attorney
OBA #
Revised 12-18-14

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