Answer And Pretrial Stipulation Offered By Respondent
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1FORM 10
COURT OF EXISTING CLAIMS
THIS SPACE FOR COURT USE ONLY
1915 NORTH STILES, STE 127
Send original to
OKLAHOMA CITY, OKLAHOMA 73105-4918
Court of Existing Claims and 1 copy to
Claimant or the Claimant’s Attorney of
Record
In re claim of:
Full Name of Injured Employee (Claimant)
Claimant’s Social Security Number (LAST 4 DIGITS ONLY)
ANSWER AND PRETRIAL STIPULATION OFFERED BY RESPONDENT
XXX-XX-_____________________
WCC FILE NO.
Name of Employer (Respondent)
Date of Injury
Employer’s Insurance Carrier, Permit # for Court Approved Individual Self-Insured
or Own Risk Group, Uninsured
NOTE: Mediation is available to address certain workers’ compensation disputes. For information, call (918) 581-2714.
YES
NO
(Please Type or Print)
________ ________
1. Was claimant at the time of the alleged injury, an employee of the above named respondent?
________ ________
2. Was claimant covered by the Workers’ Compensation Code?
________ ________
3. Did claimant sustain an accidental injury or suffer an occupational disease arising out of and in the course of the
employment?
________ ________
4. Has claimant filed a Form 3 within the statutory period of time?
________ ________
5. Did respondent, at the time of the alleged injury, have an own-risk permit or a compensation insurance policy with the carrier
named in the caption above?
________ ________
6. Did claimant timely notify respondent of the injury?
________ ________
7. Has claimant been provided medical treatment?
________ ________
8. Has respondent commenced payment of temporary total disability payments to claimant?
Temporary total disability has been paid to claimant from ________________________ to ______________________ for a
total of _______________________ weeks in the total sum of $______________________________ .
________ ________
9. Has respondent selected a treating physician?
The treating physician is ___________________________________________________ (name of treating physician).
(ALL DEPOSITIONS OF MEDICAL EXPERTS SHALL BE COMPLETED PRIOR TO TRIAL)
________ ________
10. Is rate an issue? Claimant’s compensation rate: TTD __________________ PPD/PPI ________________.
11. State all affirmative defenses: _______________________________________________________________________________________________
________________________________________________________________________________________________________________________
12. List the names of all witnesses who may be called by respondent at trial:
____________________________________________________________
________________________________________________________________________________________________________________________
13. List all exhibits to be introduced at trial: ________________________________________________________________________________________
________________________________________________________________________________________________________________________
14. Respondent hereby certifies that a copy of the medical report written by Dr. ___________________________________ and dated _______________,
was mailed, together with a copy of this motion to Opposing party/Counsel.
(LIST ON A SEPARATE SHEET, ADDITIONAL WITNESSES, EXHIBITS AND MEDICAL EVIDENCE)
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 COPY HAS BEEN SENT TO:
Signed this ________________day of______________________,___________.
Opposing Party
Signature of Filing Party
Address (Number & Street)
Address (Number & Street)
City
State
Zip Code
City
State
Zip Code
Telephone # of Filing Party
Print or type Name of Attorney
OBA #
Rev. 06/24/2015
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