Form 3b - Employee'S First Notice Of Occupational Disease And Claim For Compensation

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FORM 3B
COURT OF EXISTING CLAIMS
THIS SPACE FOR COURT USE ONLY
1915 NORTH STILES, STE 127
Send original and 4 copies to:
OKLAHOMA CITY, OK 73105-4918
Court of Existing Claims
Please check appropriate box
I. Original Filing
II. Amends Previously Filed Form 3B (Must
Name of Claimant (Injured Employee)
clearly state whether amendment is in
addition
to,
or
substitute
for,
prior
information.)
Name of Employer
EMPLOYEE’S FIRST NOTICE OF OCCUPATIONAL DISEASE AND CLAIM FOR COMPENSATION
WCC FILE NO.
Court use only
NOTE: Mediation is available to address certain workers' compensation disputes.
(Please type or print)
For information, call (918) 581-2714.
Social Security #:
Phone:
EMPLOYEE NAME (Last, First, Middle):
(
)
NOTE: A voluntary Mediation Program to address certain workers’ compensation disputes is available through the Court of Existing Claims. For
information, call (405) 522-8760 or (800) 522-8210.
Mailing Address (include City, State & Zip):
Date of Birth:
Age:
Sex:
Occupation:
Was your employment agreement in
Avg. Weekly Wage:
Length of Employment

months_____________ years_________
Oklahoma?
YES
NO
Date of last exposure to hazard which caused
Date of first distinct manifestation:
Place of Injury: City/County/State
disease:
Nature of Disease (example: Reduced breathing capacity or loss of vision)
Body Part(s) Injured:
Describe how you were exposed to the disease with details of how event occurred. Include object or substance which directly injured you:
Have you filed a claim for Social Security Disability Insurance Benefits?
Are you eligible for Medicare Benefits or will you become eligible for Medicare Bene-
fits within 30 months of the filing of this Notice of Occupational Disease and Claim

YES
NO

for Compensation?
YES
NO
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 from the Multiple Injury Trust Fund. A claim for benefits for combined disabilities against the Multiple Injury Trust
Fund may be commenced by filing a “Form 3F” with the Court of Existing Claims.
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 Occupational
Disease
and Claim
For
Compensation, permission is given to the Administrator of the Court of
Name of claimant’s attorney if represented:
Existing Claims, the Insurance Commissioner, the Attorney General, a
Type or Print Name of Attorney:
OBA#
district attorney or their designees to examine all records relating to the
notice. The permission granted to the above named persons authorizes
them access to medical records pursuant to 76 O.S., § 19, including waiver
Mailing Address:
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 by personal examination. This form is not intended
City
State
Zip
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 of
Occupational Disease 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)
Rev. 06/24/2015

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