Claimant'S Application And Order For Dismissal printable pdf download

THIS SPACE FOR COURT USE ONLY

COURT OF EXISTING CLAIMS

FORM 100

1915 NORTH STILES, STE 127

OKLAHOMA CITY, OKLAHOMA 73105-4918

Send original + 3 copies to

Court of Existing Claims

In re claim of:

Full Name of Claimant (Injured Employee)

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

XXX-XX-_________________________

CLAIMANT’S APPLICATION AND ORDER FOR DISMISSAL

Name of Employer (Respondent)

WCC FILE NO.

Date of Injury

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

Risk Group

The claimant moves to DISMISS the above referenced claim pursuant to 85 O.S. § 319, and in support thereof, states:

YES

Please mark the appropriate YES/NO response to the left of each numbered question.

1. The filing fee of $140.00 has been paid and a receipt evidencing payment is attached to this

_______

application.

(Payment of the fee is required to effect the dismissal. 85 O.S., §319.)

2. The claimant is represented by counsel.

_______

3. A permanent total disability order, permanent partial disability/permanent partial impairment order, or

Settlement Agreement has been entered. (An order of dismissal is permissible at any time before final

_______

submission of the case to the Court for decision. 85 O.S., §319.)

4. This request is for a dismissal with prejudice. (Prior to entering an order for dismissal with prejudice,

_______

the Court may require an evidentiary hearing.)

Note: If a workers’ compensation claim is timely filed and then dismissed without prejudice, the claim may be refiled within one

(1) year from the date the Order of Dismissal Without Prejudice is filed, even if the limitations period has run.

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:

Opposing Party(ies)

Signed this ___________ day of _____________________, _________

Address (Number & Street)

Signature of Claimant

City

State

Zip Code

Print or type name of Attorney for Claimant

OBA #

Claimant

Signature of Attorney of Claimant

Address (Number & Street)

City

State

Zip Code

Telephone # of Claimant

IT IS THEREFORE ORDERED, for good cause shown, that the above captioned claim is dismissed :

_______ With Prejudice

________ Without Prejudice

The filing of this order does not adjudicate the rights of any health care provider that has provided reasonable and necessary

medical care to the claimant for a work related injury.

BY ORDER OF __________________________________________________

________________________

Date of Order

Rev. 06/24/2015

Claimant'S Application And Order For Dismissal

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