Fill and Sign the Employees Faq Oklahoma Workers Compensation Court of Form

WORKERS’ COMPENSATION COMMISSION 1915 NORTH STILES AVENUE OKLAHOMA CITY, OK 73105 CC-FORM -3F USE FOR SUBSEQUENT INJURY OCCURRING ON OR AFTER FEBRUARY 1, 2014 Send original to: Workers’ Compensa�on Commission and 1 copy to the Mul�ple Injury Trust Fund and 1 copy to the Oklahoma State Treasurer Full Name of Claimant (Injured Employee) MULTIPLE INJURY TRUST FUND P.O. Box 528801 Oklahoma City, OK 73152 EMPLOYEE’S NOTICE OF CLAIM FOR BENEFITS FROM THE MULTIPLE INJURY TRUST FUND COMMISSION FILE NO. (Please type or print) FULL NAME OF EMPLOYEE (Last, First, Middle) Social Security # (LAST 4 DIGITS ONLY) XXX -XX -________________ Phone: ( ) Mailing Address (include City, State, & Zip) Date of Birth: Age: Sex: Commission File Number for most recent injury Date of Order Percentage of Disability Awarded and Body Part Date of Injury Amount of Joint Pe��on Se�lement or Other Se�lement Rate of weekly compensa�on for permanent par�al disability at the �me of the most recent injury Commission File No. Date of Injury Date of Order % of Disability & Body Part Amount of Joint Pe��on Se�lement or Other Se�lement P R I O R Are weekly bene�ts s�ll being paid on any of the above orders? YES NO  If so, when are bene�ts expected to terminate? List and describe fully any other pre-exis�ng disability for which no award has been made. (Pre -exis�ng disability means any obvious and apparent disability resul�ng fr om any cause, which disability is obvious and apparent from observa�on of a per son who is not skilled in the medical profession.) Name of Claimant’s A�orney, if represented: Type or Print Name of A�orney: OBA # Mailing Address: City: State: Zip: Telephone #: ( ) ___________________________________________________ _____________________ Signature of A�orney for Claimant (if any) The undersigned declare under PENALTY OF PERJURY that they have examined t his No�ce of Claim for Bene�ts from the Mul�ple Injury Trust Fund and all statements contained herein are true, correct and complete, to the best of their knowledge and belief. Addi�onally, the undersigned cer�fy that a true and correct copy of this No�ce of Claim was mailed to the MULTIPLE INJURY TRUST FUND and to the OKLAHOMA STATE TREASURER on the date noted below. Signed this __________day of_____________________________ __ , _____________. Revised 03-23 -15 ___________________________________________________ _____________________ Signature of Claimant (Must be signed by Claimant) THIS SPACE FOR COMMISSION USE ONLY Please check appropriate box I. Original Filing II. Amends Previously Filed CC -Form -3F. (Highlight the change and iden�fy whether it adds to or replaces the prior informa�on.) Administra�ve Workers’ Compensa�on Act, 85A O.S., §6(A)(1)(a): “Any person or en�ty who makes any material false statement or representa�on, who willfully and knowingly omits or conceals any mate rial informa�on, or who employs any device, scheme, or ar��ce, or who aids and abets any person for the purpose of: (1) obtaining any bene �t or payment … shall be guilty of a felony.” Any person who commits workers’ compensa�on fraud, upon convic �on, shall be guilty of a felony punishable by imprisonment, a �ne or both. OKLAHOMA STATE TREASURER 2300 N. Lincoln Boulevard, Room 217, State Capitol Bldg. Oklahoma City, OK 73152 Email: