Fill and Sign the Cc Form 13 Request for Prehearing Conference Oklahoma

CC-FORM -20 Send original to: Workers’ Compensation Commission and 1 copy to All Other Parties of Record WORKERS’ COMPENSATION COMMISSION 1915 NORTH STILES AVENUE STE 231 OKLAHOMA CITY, OKLAHOMA 73105 Full Name of Deceased Employee Full Name of Person Filing Proof of Loss Name of Employer Employer’s Insurance Carrier, Permit # for Court Approved Individual Self -Insured or Own Risk Group, Uninsured IN THE MATTER OF THE DEATH OF PROOF OF LOSS (DEATH CLAIM) COMMISSION FILE NO . Deceased Employee’s Social Security Number (LAST 4 DIGITS ONLY) XXX-XX -_____________________ STATE OF OKLAHOMA ) ) SS. COUNTY OF ___________________________) (PLEASE TYPE OR PRINT) __________________________________________________ , (name of person filing proof of loss) of lawful age, being first duly sworn on oath, alleges and states: The affiant is the ______________________________________________, (relation to deceased employee) of the deceased employee. The above named deceased sustained a compensable accidental injury on or about _____________________________, ___________ while in the employ of the employer, from and as a result of which the deceased died on ______________________________________, ____________. At the time of death, the deceased was lawfully married to _______________________________________________________________ (name of spouse) whose address is ____________________________________________________________________ and left surviving the following named children and dependents: CHILDREN (List additional children on the back of this form.) FULL NAME DATE OF BIRTH ADDRESS 1. ____________________________________________________________ ___________________ ____________________________________________ 2. ____________________________________________________________ ___________________ ____________________________________________ 3. ____________________________________________________________ ___________________ ____________________________________________ 4. ____________________________________________________________ ___________________ ____________________________________________ DEPENDENTS (Parents, if ACTUALLY DEPENDENT under the workers’ compensation laws of Oklahoma.) FULL NAME DATE OF BIRTH ADDRESS 1. ____________________________________________________________ ___________________ ____________________________________________ 2. ____________________________________________________________ ___________________ ____________________________________________ 3. ____________________________________________________________ ___________________ ____________________________________________ 4. ____________________________________________________________ ___________________ ____________________________________________ I affirm I have read this Proof of Loss and declare under PENALTY OF PERJURY that all statements are true and accurate to the best of my knowledge and belief. I certify that on ______________________________________________, ____________, I mailed a copy of necessary marriage, birth and death certificates to the opposing party/counsel as noted below. NOTE: A certified copy of each of these documents, and other documents necessary to establish actual dependency as defined by law, must be offered at the time of hearing or settlement. Revised 2-2- 16 Opposing Party Address (Number and Street) City State Zip Code Name of Claimant’s Attorney, if represented OBA # Address of Attorney (Include City, State and Zip Code) Telephone # Signature of Claimant’s Attorney, if any DATE ________________________________________________________________________________________________________________ Signature of Person Completing this Proof of Loss DATE I HEREBY CERTIFY THAT A COPY HAS BEEN SENT TO: THIS SPACE FOR COMMISSION USE ONLY (PLEASE TYPE OR PRINT) Administrative Workers’ Compensation Act, 85A O.S., §6(A)(1)(a): “Any person or entity who makes any material false statement or representation, who willfully and knowingly omits or conceals any material information, or who employs any device, scheme, or artifice, or who aids and abets any person for the purpose of: (1) obtaining any benefit or payment … shall be guilty of a felony.” Any person who commits workers’ compensation fraud, upon conviction, shall be guilty of a felony punishable by imprisonment, a fine or both.