Request For Claims File Information/prior Claims Request For Claims File Information/prior Claims

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Please return this form to the address listed below along with all appropriate documents and a self addressed
stamped envelope. Please note: This request will not be processed if the self-addressed stamped envelope is
not provided. (Please note: There is a $1 charge per search conducted.)
Oklahoma Court of Existing Claims
Attn: Records Department
1915 N Stiles Ave
Oklahoma City, OK 73105
-------------------------------------------------------------------------------------------------------------------------------------
Fold along dotted line. Place in a window envelope so that the address appears.
REQUEST FOR CLAIMS FILE INFORMATION/PRIOR CLAIMS
REQUEST FOR CLAIMS FILE INFORMATION/PRIOR CLAIMS
REQUEST FOR CLAIMS FILE INFORMATION/PRIOR CLAIMS
REQUEST FOR CLAIMS FILE INFORMATION/PRIOR CLAIMS
Please indicate
the TYPE
of search you are requesting (please type or print):
By Name
By Social Security Number (Requires Authorization from holder
of Social Security Number as evidenced by signature below)
First Name
First Name
Last Name
Last Name
I authorize the use of my social security number to search for workers’
compensation information as evidenced by my signature:
Signature of SS# Holder:
Date
Social Security #:
This search is being made on behalf of the
following:
Name: _________________________________________________________________
Address : _______________________________________________________________
City: _______________________________ State: _____ Zip Code: ______________
Please indicate your information below (the preparer of this form):
I declare under PENALTY OF PURJURY
PENALTY OF PURJURY
PENALTY OF PURJURY
PENALTY OF PURJURY that the information sought hereby is not for a purpose in violation
of any state or federal law. I understand that I am required by law to disclose the person for whom this search
request is being made, if different from myself.
Preparer's Signature
Preparer’s Printed Name:
Telephone #
Address:
City:
State:
Zip Code:
This document is considered a public record under Oklahoma state law.
C. 02/01/2014

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