Copy Request Form

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OKLAHOMA COURT OF EXISTING CLAIMS
FOR COURT USE ONLY
Rev. 06/24/2015
C O P Y
R E Q U E S T
F O R M
Oklahoma Court of Existing Claims
SUBMIT
ATTENTION: Copy Requests
REQUEST
1915 North Stiles, Ste 127
FORM TO
Oklahoma City, OK 73105-4918
Company Name: ______________________________________
FEE FOR FILES PULLED
COPIES
Attention: _____________________________ Telephone: ( _____ ) _______________
TO BE
Address: ______________________________________________________________
PAID
RETURNED TO
City/State/Zip: ______________________________________________________________
EXEMPT
FOR EACH COURT FILE NUMBER YOU MUST:
INQUIRIES
1.
Use a Separate Copy Request Form, and
General Inquiries . . . Records Dept. (405) 522-8640
2.
Complete and Sign Part I of this form, if applicable, OR if not applicable, Complete and
Records Management Dept. Supervisor . . . Katrina Stephenson (405) 522-8640
1
Sign Part II of this form and Include a $1 Search Fee.
Claimant’s Name
Date of Injury
WCC File No.
❒ FORM A
Change of Physician
❒ ORDER Entered on ______/______/______
❒ FORM 3
Employee’s First Notice of Accidental Injury & Claim for Compensation
❒ ALL ORDERS
❒ ENTRIES OF APPEARANCE
❒ SUBSTITUTION OF ATTORNEY
❒ FORM 3A Claimant’s First Notice of Death & Claim for Compensation
❒ ATTORNEY WITHDRAWALS
❒ FORM 3B Employee’s First Notice of Occupational Disease & Claim for
❒ ALL MEDICAL REPORTS
Compensation
❒ FORM 19
Request for Payment of Charges for Medical or Rehabilitative
❒ FORM 3F
Employee’s Claim for Benefits from the Multiple Injury Trust Fund
Services - Notice of Appeal of Administrative Order
❒ FORM 9
Motion to Set for Trial
❒ FORM 20
Proof of Loss (Death Claim)
❒ WITH ATTACHMENTS
❒ FORM 10
Answer & Pretrial Stipulation Offered by Respondent
❒ ENTIRE FILE Files May Contain Duplicate Documents . . . BILLING IS FOR ALL
❒ WITH ATTACHMENTS
COPIES, INCLUDING DUPLICATES
❒ OTHER (Specify)
❒ FORM 13
Request for Prehearing Conference
❒ Settlement Agreement (Form CS-337, Form CS-339-A, Form CS-339-B, Other)
❒ WITH ATTACHMENTS
PART I. STATEMENT OF EXEMPTION: By signing below, I affirm that I meet the requirements of an exemption from the written request and Search Fee requirements
of Title 85 O.S. Section 372, as indicated below, and that the information sought is not requested for any non-exempt purpose; provided, however, an employer or
personnel service company claiming EXEMPTION #6 ALSO MUST COMPLETE PART II OF THIS FORM. Please circle the number of the exemption that applies:
EXEMPTIONS
1.
Requests made by a public officer or public employee in the performance of his/her duties on behalf of a governmental entity, or as may be allowed by law;
2.
Requests made by an insurer, self-insured employer, third-party claims administrator, or a legal representative thereof, when necessary to process or defend a
workers’ compensation claim;
3.
Requests made by a worker or worker’s representative for the worker’s claim information;
4.
Disclosures made for educational or research purposes, in such a manner that the disclosed information cannot be used to identify any worker who is the subject of a
claim;
5.
Requests made by a health care or rehabilitation provider, or legal representative thereof, when necessary to process payment for services rendered to a worker;
6.
Requests made by an employer or personnel service company where the worker executes a written authorization permitting the search and designating the
employer or personnel service company as the worker’s representative for that purpose. (The written authorization must be submitted with this form.)
Your Signature:____________________________________________________Printed Name:______________________________________________________
Telephone No: (______)_____________ Address: _________________________________________ City: _____________________ State: _____ Zip: _____
PART II. COMPLETE THIS IF EXEMPTION #6 (ABOVE) IS CLAIMED OR IF NONE OF THE OTHER EXEMPTIONS LISTED ABOVE APPLY:
By signing below, I declare under PENALTY OF PERJURY that the information sought is not for a purpose in violation of any state or federal law. I understand I am
required by law to disclose the person for whom this search request is being made, if different from myself. This search is being made for:
(Name and address of person for whom this search is being made, IF OTHER THAN THE UNDERSIGNED. Please PRINT.)
Name_______________________________________________________ Full Address ____________________________________________________________
Your Signature:___________________________________________________ Printed Name:________________________________________________________
Telephone No: (______)_____________ Address: _________________________________________ City: _____________________ State: _____
Zip: ______
NOTE ➦ ➦ Please Return A Copy Of This Copy Request Form And Invoice With Your Check Made Payable To The Court of Existing Claims
Invoice No.________________________________ Invoice Date:____________________________
______________ COPIES @ $1.00 per copy (85 O.S., §370) = $________________________
Total amount due: $____________________
1
POSTAGE = $_________________________
NOTE: BY LAW, THE $1 SEARCH FEE, IF APPLICABLE, MUST
ACCOMPANY THE COPY REQUEST WHEN MADE.

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