Fill and Sign the Certificate to Settle by Compromise Settlement New 07 05pub Form

Before the Workers’ Compensation Court of the State of Oklahoma In re claim of: Claimant ) File Number ) ) Respondent ) ) ) Claimant’s Social Insurance Carrier ) Security Number: CERTIFICATE TO SETTLE BY COMPROMISE SETTLEMENT 1. The claimant certifies that he has notified the Respondent of all medical providers who have provided medical treatment, including physical therapy, as a result of the accidental injury while employed by Respondent. A list of all medical providers who have provided treatment is attached hereto as Exhibit A. Further, the Claimant represents and agrees that he/she will notify all future medical providers for the accidental injury while employed by the Respondent that the claim against the Respondent has been settled by Compromise Settlement. Claimant 2. The Respondent’s attorney certifies that a copy of the Compromise Settlement will be provided to all known medical providers, including physical therapists, who have provided treatment to the claimant, within ten (10) days of the settlement. The Respondent’s attorney shall also notify the medical providers that the Compromise Settlement specifies that the Respondent will not be responsible for treatment rendered after the date of the Compromise Settlement. Respondent - over - c. 07/05 EXHIBIT “A” TO CERTIFICATE TO SETTLE BY COMPROMISE SETTLEMENT The following Medical Providers have provided medical treatment, including physical therapy, as a result of the accidental injury while employed by Respondent: Name Address, City State Zip