Employee'S Claim For Benefits For Combined Disabilities Against The Last Employer printable pdf download

COURT OF EXISTING CLAIMS

THIS SPACE FOR COURT USE ONLY

FORM 3E

1915 NORTH STILES, STE 127

OKLAHOMA CITY, OK 73105-4918

Send original to

Court of Existing Claims and 1 copy to

Please check appropriate box

Opposing Party/Counsel

I. Original Filing

Name of Claimant (Injured employee)

II. Amends Previously Filed Form 3E (Must

clearly state whether amendment is in

Name of Employer

addition

to,

substitute

for,

prior

information.)

Employer’s Insurance Carrier, Permit # for Court Approved Individual

Self-Insured or Own Risk Group, Uninsured

EMPLOYEE’S CLAIM FOR BENEFITS FOR COMBINED

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

DISABILITIES AGAINST THE LAST EMPLOYER

For information, call (918) 581-2714.

WCC FILE NO.

(Please type or print)

EMPLOYEE NAME (Last, First, Middle)

Social Security #

Phone:

(

)

Mailing Address (include City, State & Zip)

Date of Birth

Age:

Sex:

Court File Number for most recent injury

Date of Injury

Date of Order

Percentage of Disability Awarded and Body Part

Amount of Joint Petition or Other Settlement

Rate of weekly compensation for permanent partial disability at the time of

the most recent injury

Court File No.

Date of Injury

Date of Order

% of Disability & body Part

Amount of JP or Other

Settlement

Are weekly benefits still being paid on any of the above orders? _________________ YES ___________________ NO If so, when are benefits expected

to terminate? _____________________________________________________________

List and describe fully any other pre-existing disability for which no award has been made.

(Pre-existing disability means any obvious and

apparent disability resulting from any cause, which disability is obvious and apparent from observation of a person who is not skilled in the medical profession.)

_____________________________________________________________________________________________________

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.

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

I hereby certify that a true and correct copy of this claim was mailed to

Upon filing this Claim For Benefits for Combined Disabilities Against the

the above named employer or its counsel on the _____________day of

Last Employer, permission is given to the Administrator of the Court of

___________,_______.

Existing Claims, the Insurance Commissioner, the Attorney General, a

district attorney or their designees to examine all records relating to the

Name of claimant’s attorney if represented:

claim. The permission granted to the above named individuals or their

Type or Print Name of Attorney:

OBA #

designees authorizes them access to medical records pursuant to Section

19 of Title 76 of the Oklahoma Statutes, including waiver of any privilege

granted by law concerning communications made to a physician or health

Mailing Address:

care provider or knowledge obtained by such physician or health care

provider by personal examination.

City

State

Zip

Telephone #:

Signed this ______________ day of_____________________, ________

(

)

Signature of Attorney for Claimant

Signature of Claimant (must be signed by claimant)

Rev. 06/24/2015

Employee'S Claim For Benefits For Combined Disabilities Against The Last Employer

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