Memorandum Of Agreement As To Fact With Relation To An Injury And Payment Of Disability Compensation
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1THIS SPACE FOR COURT USE ONLY
FORM 26
COURT OF EXISTING CLAIMS
1915 NORTH STILES
Send Original and 3 copies to
OKLAHOMA CITY, OK 73105-4918
Court of Existing Claims
Full Name of Claimant (Injured Employee)
Claimant’s Social Security Number
MEMORANDUM OF AGREEMENT AS TO FACT WITH RELATION TO AN
Name of Respondent (Employer)
INJURY AND PAYMENT OF DISABILITY COMPENSATION
FILE NO.
Employer’s Insurance Carrier, Permit # for Court Approved Individual Self-
Insured or Own Risk Group, Uninsured
Date of Injury
(Please type or Print ALL information legibly in ink)
We, the above named parties, agree to pay and accept compensation as provided herein based on the following facts and pursuant
to 85 O.S., Section 26:
1.
That the claimant sustained an accidental injury on __________________________, ______, at (time) _________ arising out of and in the
course of employment with the employer. The nature of the injury was _________________________________________________,
resulting in temporary total disability from _______________________, _________ to ________________________, _________ or for
a period of _________ weeks, for which claimant received $____________________ in compensation, computed at _____________per
week, based upon claimant’s hourly wage of ____________.
2.
That claimant timely notified the employer of the injury; that claimant’s employment was covered by the Workers’ Compensation Act and
that this Court has jurisdiction in the matter.
3.
That as a result of the injury, respondent or insurance carrier agrees to pay to the claimant the sum of $_____________________, same
being for permanent disability (_______%) to ____________________________________________________________; to pay
authorized, reasonable and necessary medical expenses incurred by claimant by reason of the injury, and comply herewith within 20 days
of the file-stamped date of this Form 26.
4.
The sum of $____________________ shall be deducted from this settlement amount and paid to the claimant’s attorney as a fair and
reasonable fee. Claimant ACCEPTS the fee amount and payment method, and WAIVES THE RIGHT TO A FEE HEARING
(____claimant’s initials). Claimant REJECTS the fee amount and payment method and REQUESTS A FEE HEARING (____claimant’s
initials).
5.
The respondent or insurance carrier shall pay court costs in the amount of $140.00, in each case, unless the Court cost was previously
paid; the Special Occupational Health and Safety Tax in the sum of $_______________________, representing three-fourths of one
percent (0.75%) of the entire settlement amount, excluding medical payments and temporary total disability; and the respondent, if OWN
RISK, shall also pay the sum of $____________________, representing 2% of the total compensation for permanent disability and death
benefits to the Workers’ Compensation Administration Fund and the sum of
$_____________________, representing 1% of the total
compensation for permanent partial disability to the appropriate Self-Insured Guaranty Fund, if applicable by law.
6.
In addition to other amounts, the respondent, if UNINSURED, shall pay a Multiple Injury Trust Fund assessment in the sum of
$_______________________, representing 5% of the total compensation paid for permanent disability and death benefits.
7.
It is further agreed by and between the above named parties that this agreement shall not be final if a change in claimant’s
condition occurs or arises, in which case, the agreement may be reopened and reviewed in the same manner as a change of
condition.
We, the undersigned, declare under penalty of perjury that we have examined this agreement and all statements
contained herein, and to the best of our knowledge and belief, they are true, correct and complete. ANY PERSON WHO
COMMITS WORKERS’ COMPENSATION FRAUD, UPON CONVICTION, SHALL BE GUILTY OF A FELONY.
Signed this _____ day of ____________________, _______.
Signed this _____ day of ____________________, _______.
Signature of Claimant
Employer or Respondent
X
Claimant’s Address
Name of Insurance Carrier or Own Risk Group
Name of Claimant’s Attorney
OBA #
Type or Print Name of Attorney for Respondent/Insurer
OBA #
Signature of Claimant’s Attorney
Signature of Attorney for Respondent/Insurer
X
X
C. 02/01/2014
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