Fillable Request For Prehearing Conference printable pdf download

FORM 13

THIS SPACE FOR COURT USE ONLY

COURT OF EXISTING CLAIMS

Send original to

1915 NORTH STILES, STE 127

Court of Existing Claims and 1 copy to

OKLAHOMA CITY, OKLAHOMA 73105-4918

All Other Parties of Record

(Please type or print)

In re claim of:

Full Name of Claimant (Injured Employee)

Claimant’s Social Security Number (LAST 4 DIGITS ONLY)

XXX-XX-_________________________

REQUEST FOR PREHEARING CONFERENCE

Name of Employer or Respondent

WCC FILE NO.

Employer’s Insurance Carrier, Permit # for Court Approved Individual Self-Insured or Own

Date of Injury

Risk Group, Uninsured

NOTE: Mediation is available to address certain workers’ compensation disputes. For information, call (918) 581-2714.

Movant respectfully requests that the captioned cause be set for Prehearing Conference at the earliest possible date to address the

following issue(s):

a. Motion to Terminate Temporary Compensation.

b. Objection to Termination of Temporary Compensation based on:

Court Appointed IME

Treating Physician

85 O.S. Section 332(G)

Other _______________________________________ (Specify)

c. Motion to Appoint an Independent Medical Examiner.

d. Employer Objection to Claimant’s Request for Change of Physician.

e. Motion to Consolidate. LIST ALL COURT FILE NUMBERS, EXCLUDING THE ONE LISTED ABOVE.

____________

Motion to Hold in Abeyance.

g. Motion to Join Additional Parties. Include the name and complete address, including the zip code, of EACH additional party

and INSURER, and the alleged DATE OF INJURY. (Use additional sheets if necessary.) A COPY OF THIS MOTION MUST BE

MAILED TO EACH ADDITIONAL PARTY AND INSURER LISTED.

Alleged Date of Injury

Additional Party & Address, including City/State/Zip

Insurer & Address, including City/State/Zip

____________________________________ | __________________________________________ | _____________________

h. Mediation Order. (Note: Contact the Counselor Department directly to pursue mediation by mutual agreement without Court order.)

i. Motion to Review Permanent Total Disability Status pursuant to 85 O.S., Section 336(C).

j. Other __________________________________________________________________________________________ (specify).

Has a trial judge previously been assigned by the Court to hear all matters relating to the above-captioned cause of action?

YES

ASSIGNED TRIAL JUDGE: ___________________________________.

THE PARTY MAKING THIS REQUEST FOR A PREHEARING CONFERENCE HEREBY CERTIFIES THAT THE PARTIES HAVE DISCUSSED THE ISSUE

TO BE PRESENTED TO THE COURT AND CANNOT, IN GOOD FAITH, REACH A RESOLUTION OF THE ISSUE WITHOUT THE COURT’S ASSISTANCE.

I declare under penalty of perjury that I have examined all statements contained herein and they are true, correct and complete, to the best of my

knowledge and belief. 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/Counsel

Signature of Requesting Party

Address

Address (Number and Street)

City

State

Zip Code

City

State

Zip Code

Telephone Number of Requesting Party

Print or type name of Attorney

OBA #

Rev. 06/24/2015

Request For Prehearing Conference

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