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Employer's Application for Hearing

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Application for Appointment as Certified Workers’ Compensation Mediator

THIS SPACE FOR COMMISSION USE ONLY

CC-FORM-926

Please complete this form, sign under penalty of perjury and return with a current resume to the: Workers' Compensation Commission, Attention: Counselor Division, 1915 N. Stiles Avenue, Oklahoma City, OK 73105. This application is for a 5-year term. NOTE: Failure to provide all requested information may delay consideration of your application.

ALL INFORMATION SUBMITTED TO THE COMMISSION MAY BE CONSIDERED A PUBLIC RECORD UNDER STATE LAW.

Direct all questions regarding disclosures to the Counselor Division.

1. Are you an active or senior member in good standing of the Oklahoma Bar Association?

2. Are you a non-attorney mediator certified pursuant to the requirements of the Dispute Resolution Act, 12 OS, §1801 et seq.?

3. Have you worked in the area of workers’ compensation benefits for at least 5 years?

4. Are you knowledgeable of Oklahoma workers’ compensation laws, Commission Rules, the Oklahoma workers' compensation system, the 6th Edition of the AMA Guides to the Evaluation of Permanent Impairment and the Official Disability Guidelines (ODG) published by the Work Loss Data Institute?

5. Describe your training and/or experience as a mediator. (Attach an extra page if necessary.):

6. Describe your training and/or experience evidencing knowledge of workers’ compensation laws, Commission Rules, the Oklahoma workers’ compensation system, the 6th Edition of the AMA Guides to the Evaluation of Permanent Impairment and the Official Disability Guidelines (ODG) published by the Work Loss Data Institute. (Attach an extra page if necessary.):

7. Have you, within the twelve (12) months immediately preceding this application:
(a) completed six (6) hours of mediation training approved by the Oklahoma Bar Association MCLE Commission or sponsored by the Workers' Compensation Commission, AND
(b) observed or mediated at least two (2) workers’ compensation mediation sessions?

NOTE: If you answer YES to question(s) 8 and/or 9, please provide an explanation of each on a separate page and attach to this application.

8. Have you been the subject of any disciplinary proceedings in any state for misconduct as a licensed professional that resulted in disbarment, suspension, public censure, private reprimand, or revocation of your professional license?

9. Have you been convicted of a felony or of a crime involving dishonesty or false statement?

10. Will you comply with the Commission’s mediation procedures?

I hereby request appointment to the Workers' Compensation Commission’s list of certified workers’ compensation mediators, and certify that I meet the minimum requirements for certification as a workers’ compensation mediator pursuant to 85A O.S., §110 and the Commission’s rules. Upon receipt of a Commission order to serve as a mediator of a claim, I agree to schedule a mediation session within thirty (30) days of the order of appointment, unless otherwise agreed by the parties. I agree to schedule mediations for a minimum two-hour block of time, and to schedule not more than one mediation to take place at a time. I agree to conduct up to two (2) pro bono mediations annually if requested by the Workers' Compensation Commission. I agree to submit biennially to the Commission’s Counselor Division written verification of compliance with the continuing education requirements set by 85A O.S., §110. I agree to accept as payment in full an amount not to exceed the maximum rate or fee set forth in Rule 810:10-3-12 of the Workers’ Compensation Commission for services rendered as a certified workers' compensation mediator. I agree to comply with all applicable statutes and the rules of the Workers' Compensation Commission. I agree to comply with all applicable standards of impartiality and confidentiality.

I hereby authorize any and all associations, organizations and State and Federal agencies to release to the Workers' Compensation Commission upon request, any and all documents and information necessary and relevant to the investigation and approval of this application.

I declare under PENALTY OF PERJURY that the statements contained herein are true and correct to the best of my knowledge and belief. I understand that false or misleading information may result in rejection of my application or, if previously appointed, in removal from the list of certified workers' compensation mediators.

Revised 12-18-14

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What the Employer's Application for Hearing Is and When It Applies

The Employer's Application for Hearing is a formal, written request submitted by an employer to challenge, appeal, or seek review of an administrative determination affecting the employer — for example, unemployment insurance chargeability, wage-and-hour findings, or agency penalty assessments. The form identifies the employer, the agency case or determination being disputed, and the specific grounds for requesting an evidentiary hearing or administrative review. Submitting this application starts a procedural timeline for notices, discovery, and a hearing before an administrative law judge or tribunal.

Why filing this application matters for employers

Filing a timely, complete application preserves the employer's right to present evidence, question witnesses, and seek a binding administrative decision that may reverse, modify, or reduce agency actions or financial liabilities.

Why filing this application matters for employers

Who typically completes an Employer's Application for Hearing

The application can be submitted by an authorized employer representative; confirm authority and include contact information for hearing scheduling and service.

  • Human resources or payroll departments responsible for unemployment tax and claims management, including documentation of wages and separations.
  • Internal legal or compliance teams handling agency audits, penalty notices, or regulatory determinations on behalf of the company.
  • Outside counsel, labor attorneys, or third-party administrators submitting appeals or representing the employer at hearing.

Who can sign and submit the application

Authorized Officer

A corporate officer, owner, or other person with delegated authority may sign the application. The signer should be able to verify factual statements and present or authorize evidence at the hearing; include title and contact information.

Designated Representative

An attorney, HR manager, or third-party administrator may file and sign if the employer provides written authorization. Attach a representative authorization or power of attorney when required by the agency.

Essential components of a professional application

A complete Employer's Application for Hearing contains identifying data, a clear statement of the contested determination, grounds for appeal, supporting facts, requested relief, and signature and contact information so the agency can schedule proceedings and serve documents.

Case identification

Agency name, file or determination number, and date of the decision being appealed.

Employer information

Legal business name, DBA if applicable, EIN or tax ID, mailing address, and primary contact details.

Grounds for review

Concise legal or factual basis for contesting the decision, including statutory or procedural errors, misapplied facts, or calculation disputes.

Supporting facts

Chronology, witness names, payroll records, separation notices, and other evidence that will be offered at the hearing.

Requested relief

Specific outcomes sought, such as reversal, reduction of charges, or remand for further fact-finding.

Signature block

Name, title, date, and contact information for the signer plus representative authorization if applicable.

Step-by-step: completing and submitting the application

Follow these sequential steps to prepare a timely, complete application and reduce the risk of administrative rejection or hearing delays.

  • 01
    Gather documents: Collect the notice, payroll records, separation notices, and supporting exhibits.
  • 02
    Complete fields: Enter employer details, case number, grounds, and contact information accurately.
  • 03
    Attach evidence: Add exhibits as separate, labeled attachments for clarity and referencing.
  • 04
    Submit and confirm: Send by the agency's allowed channels and obtain confirmation or proof of receipt.

How the hearing process works after you file

Submitting the application triggers administrative steps: intake, scheduling, discovery, hearing, and written decision. Prepare to participate at each stage.

  • Intake and docketing: Agency logs the appeal, assigns an adjudicator, and notifies parties of next steps.
  • Scheduling the hearing: A hearing date and format (in-person or remote) are provided; parties may request continuances for cause.
  • Pre-hearing discovery: Parties exchange exhibits, witness lists, and motions per agency rules.
  • Hearing and decision: Evidence and testimony presented; judge issues a written decision or order afterward.

Configuring an online application workflow

Set up an online workflow to standardize submissions, collect signatures, and maintain an audit trail for each application.

Field Configuration
Case number field Required, single-line text with validation to match agency format
Date fields Use MM/DD/YYYY format and date pickers to prevent entry errors
Attachment control Allow PDF uploads, require filename convention, limit file size
Signature field Enable eSignature with signer name, timestamp, and audit trail

Delivery methods, integrations, and technical requirements

Use platforms that provide encrypted storage, audit trails, and integration adapters to reduce manual data entry and ensure compliance.

  • Accepted formats: PDF, DOCX, or agency web forms
  • Integrations: Salesforce, NetSuite, Microsoft 365, Google Workspace
  • Authentication: Email, SMS code, or ID verification

Timing: common deadlines and scheduling expectations

Adhere to agency deadlines; late submissions can forfeit hearing rights or limit available remedies.

Request deadline:

Often 10–30 days from the date of notice; check the agency letter.

Evidence exchange:

Agencies typically require exhibits several days before the hearing.

Continuance requests:

File promptly; agencies have specific timelines for granting continuances.

Decision timeframe:

Written decisions are generally issued within weeks to months after hearing.

Judicial review:

If appealing to court, different statutory deadlines apply; consult counsel.

Key milestones from filing to final decision

A sequential view of the main processing stages once an employer files an application for hearing.

01

File Application

Agency receives application and assigns a docket number.

02

Scheduling Notice

Agency issues a hearing date and instructions for participation.

03

Pre-hearing Exchange

Parties exchange exhibits, witness lists, and motions per agency rules.

04

Hearing and Decision

Administrative judge hears evidence and issues a written ruling.

Common preparation pitfalls to avoid

  • Missing or mistyped case numbers that cause misrouting and scheduling delays.
  • Submitting incomplete evidence or failing to label exhibits for easy reference at the hearing.
  • Insufficient authorization documentation when a third-party representative files on the employer's behalf.
  • Relying on unsigned or undated documents that the adjudicator may exclude as unauthenticated.

Penalties and risks of an incorrect or late application

Loss of appeal rights: Missed deadlines can forfeit hearing entitlement.
Increased liability: Original determinations may become final, increasing financial exposure.
Administrative fines: Failure to comply with discovery or orders may trigger sanctions.
Evidence exclusion: Late or unauthenticated exhibits may be excluded.
Higher counsel costs: Remediation and court appeals increase legal fees.
Reputational risk: Public or regulatory records can affect contracting and hiring.

Data and security considerations when submitting electronically

Encryption: TLS 1.2/1.3 in transit
At-rest encryption: AES-256 storage
Audit trail: Detailed signing logs retained
HIPAA readiness: BAA available when required
Certifications: SOC 2 Type II and ISO 27001
Access controls: SSO, MFA, and role-based rights

Comparing eSignature options for submitting hearing applications

Vendor pricing and core capabilities vary; signNow is listed first to align vendor ordering conventions and allow direct feature comparison.

signNow DocuSign Adobe Sign PandaDoc HelloSign
Starting Price $8/user/mo $15/user/mo $14/user/mo $19/user/mo $15/user/mo
Free Trial 7-day trial Varies by plan Varies by plan Varies by plan Varies by plan
Bulk Send Yes (Premium) Yes Yes Yes Varies
Audit Trail Yes Yes Yes Yes Yes
HIPAA Compliant Yes Yes Yes No No

Representative use cases for employer hearing applications

These examples illustrate common scenarios and how a complete application supports a favorable review or orderly hearing process.

Large employer unemployment appeal

A regional employer received multiple claimant charges after a reduction in force, disputed liability based on separation for misconduct

  • Employer compiled payroll and separation documents
  • Counsel filed a consolidated application with exhibits and witness lists, resulting in review and charge adjustments after hearing.

Small business wage dispute

A small employer contested a wage assessment citing payroll reporting errors, and sought a hearing to introduce corrected records

  • Employer provided corrected payroll registers and timecards
  • The hearing examiner accepted the corrected evidence and reduced the assessed penalty and interest.

Practical tips to complete the application accurately and efficiently

Adopt consistent document naming, standard exhibit numbering, and a checklist to ensure nothing is omitted when filing an application.

Standardize filenames
Use a consistent naming convention (CaseNumber_Exhibit_01.pdf) so agency staff and hearing officers can quickly identify and reference exhibits.
Number exhibits
Assign sequential exhibit numbers and reference them in your hearing outline to make testimony and evidence easy to follow.
Verify signer authority
Confirm the signer is authorized and attach written authorization if a representative or third party files on your behalf.
Preserve originals
Retain original signed documents and maintain copies of all submissions with timestamps and proof of delivery.

Frequently asked questions about Employer's Application for Hearing

Answers to common questions about timing, signatures, electronic submission, and preparing evidence for an employer hearing application.


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