Cc-Form-211 - Request For Review Of Adverse Benefit Determination

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THIS SPACE FOR COMMISSION USE ONLY
WORKERS COMPENSATION COMMISSION
CC-FORM-211
1915 NORTH STILES AVENUE
OKLAHOMA CITY, OKLAHOMA 73105
Send original and 4 copies to Workers’ Compensation Commission
and 1 copy to the Qualified Employer
Please type or print. Enter dates in MM/DD/YY format.
Full Name of Claimant Aggrieved by Adverse Benefit Determination of the Appeals Committee
Employee’s Social Security Number (LAST 4 DIGITS ONLY)
Date of Injury/Death
XXX-XX-_________________________
Date Claimant Received the Adverse Benefit Determination of the Appeals Committee
Name of Qualified Employer (Respondent)
Qualified Employer’s Insurance Carrier or Qualified Employer’s Designation as Self-Insured
COMMISSION FILE NO.
REQUEST FOR REVIEW OF ADVERSE BENEFIT DETERMINATION
Pursuant to 85A O.S., §211, the Claimant respectfully requests the Workers’ Compensation Commission to review an adverse benefit
determination upheld by the above named appeals committee. In support of this application, the Claimant states as follows:
1. This request is filed with the Workers’ Compensation Commission within one (1) year of the Claimant’s receipt of the notice that the
adverse benefit determination, or part thereof, was upheld by the appeals committee.
2. A true and correct copy of the adverse benefit determination being appealed to the Commission en banc is attached.
3. Following are the specific issues in the adverse benefit determination to be reviewed. General allegations of error do not suffice.
(Attach additional pages if needed.) ______________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
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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.
I declare under PENALTY OF PERJURY that I have examined all statements contained herein, and to the best of my knowledge and
belief, they are true, correct and complete.
Signed this _________ day of ______________________________________________, ______________.
Signature of Claimant
Print or Type Name of Attorney for Claimant, if any
OBA #
Claimant’s Address (Number and Street)
Signature of Attorney for Claimant
City
State
Zip
Claimant’s Attorney’s Address (Number and Street)
Claimant’s Telephone Number
City
State
Zip
Claimant’s Attorney’s Telephone Number
I HEREBY CERTIFY THAT A COPY HAS BEEN SENT TO:
Employer /Attorney for Employer
Address (Number & Street)
City
State
Zip Code
Revised 1-14-16

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