Fill and Sign the All Employees of This Employer Who Are Entitled to Benefits of the Administrative Workers Compensation Act Are Hereby Notified Form

CC -Form -1A Oklahoma Workers' Compensation Notice and Instruction to Employers and Employees All employees of this employer who are entitled to benefits of the Administrative Workers' Compensation Act are hereby notifi ed that this employer has complied with all rules of the Workers' Compensation Commission and that this employer has secured payment of compensation fo r all employees and their dependents in accordance with the Act. All employees are further notified this employer will furnish first aid, medical, sur gic al, hospital, optometric, podiatric, and nursing services, medicine, crutches and other apparatus as may be reasonably necessary in connection with the injury rec eiv ed by the employee, as well as payments of compensation to any injured employee or the employee’s dependents as provided in the Act. Any employee who has suffered a compensable injury covered by the Administrative Workers' Compensation Act is entitled to voc ational rehabilitation services, including retraining and job placement, if, as a result of the injury, the employee is unable to perform work for w hic h the person has previous training or experience. The Oklahoma Workers' Compensation Commission has a Counselor Division to provide information to injured workers, employers, and other interested persons. Mediation is available to help resolve certain workers’ compensation disputes. For information, call the Counselor Division at 405 -522 -5308 or In -State Toll Free 855 -291 -3612. Signature of Employer Insurer Name and Address Employee's Responsibilities In Case of Work Related Injury If accidentally injured or affected by cumulative trauma or an occupational disease arising out of and in the course of emplo yme nt, however slight, the employee should notify the employer immediately. If this employer is a partnership, notice shall be given to any partner. I f this employer is a corporation, notice shall be given to any agent or officer of the corporation upon whom legal process may be served. Notice shall also be given to the person in charge of business at the location of operations where the injury occurred. Unless oral or written notice is given to the employer wit hin thirty (30) days, the claim for compensation may be forever barred. The employee may file a claim for compensation with the WORKERS’ COMPENSATION COMMISSION for an accidental injury, death, cumulative trauma or occupational disease or illness occurring ON OR AFTER February 1, 2014. Forms to file a compensation claim should be furnished by this employer and also are available from the Workers’ Compensation Commission. The forms are posted on the Commission’s website, ww w.wcc.ok.gov. A claim for compensation must be filed with the Commission within the time specified by law, or be forever barred. Based on law effective February 1, 2014, a claim for compensation for any accidental injury must be filed with the Commission within one (1) year of the date of injur y; a death claim must be filed within two (2) years of the date of death; a claim for compensation for occupational disease or illness must be filed within two (2) years of the last injurious exposure; and a claim for compensation for cumulative trauma must be filed within one (1) year of the date of injury. A clai m f or additional compensation is barred unless filed within one (1) year of the last payment of disability compensation or two (2) years from the date of inju ry, whichever is longer. Claims for compensation for accidental injury, death, cumulative trauma or occupational disease or illness occurring BEFORE F ebr uary 1, 2014 may be filed with the WORKERS’ COMPENSATION COURT OF EXISTING CLAIMS and are subject to different notice of injury requirements a nd claims filing deadlines than those for accidental injury, death, cumulative trauma or occupational disease or illness occurri ng on or after February 1, 2014. Failure to comply with applicable notice requirements and deadlines may operate to forever bar the claim. Contact the WO RKERS’ COMPENSATION COURT OF EXISTING CLAIMS for additional information. Employer's Responsibilities The employer must provide employees with immediate first aid, medical, surgical, hospital, optometric, podiatric, and nursing services, medicine, crutches and other apparatus as may be reasonably necessary in connection with the injury received by the employee. This applies to care for all injuries and illnesses arising out of and in the course of employment, regardless of their character. Within ten (10) days after the date of receip t of notice or knowledge of death or injury that results in more than three days’ absence from work for the injured employee, the employer MUST send a report ther eof to the Workers’ Compensation Commission on a CC -Form 2, and also send a copy of the CC -Form 2 to the employer’s insurance carrier, if any, withi n the ten -day period. No agreement by any employee to pay any portion of the premium paid by the employer to a carrier or a benefit fund or departm ent maintained by the employer for the purpose of providing compensation or medical services and supplies as required by the workers’ compensation law s, shall be valid. Any employer who makes a deduction for such purposes from the pay of any employee entitled to benefits under the workers’ compens ation laws shall be guilty of a misdemeanor. No agreement by any employee to waive workers' compensation rights and benefits shall be valid. Any person who commits workers' compensation fraud, upon conviction, shall be guilty of a felony punishable by imprisonment, a fine or both. Workers' Compensation Commission 1915 North Stiles Avenue Oklahoma City, Oklahoma 73105 -4918 Tele. 405 -522 -5308 (OKC) · 918 -295 -3732 (TU) · In -State Toll Free 855 -291 -3612 Web Site · www.wcc.ok.gov This notice must be posted and maintained by the employer in one or more conspicuous places on the work premises. Revised 12 -18-14 Date of Expiration of Insurance Policy (Not applicable to employers authorized to self -insure.)