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WORKERS COMPENSATION COMMISSION 1915 NORTH STILES AVENUE STE 231 OKLAHOMA CITY, OKLAHOMA 73105 In re claim of: CC-FORM -13 Send original to Workers’ Compensa�on Commission and 1 copy to All Other Par�es of Record Full Name of Claimant (Injured Employee) Claimant’s Social Security Number (LAST 5 DIGITS ONLY) XXX -X _________________________ Name of Employer or Respondent Employer’s Insurance Carrier, Permit # for Commission Approved I ndividual Self-Insured or Own Risk Group, Uninsured REQUEST FOR PREHEARING CONFERENCE COMMISSION FILE NO. Date of Injury (Please type or print) NOTE: Mediation is available to help resolve certain workers’ compensation disp utes. For information, call (405) 522-5308 or In-State Toll Free (855) 291- 3612. 1. A request is made for the cap�oned case to be set for Prehearing Conference at th e earliest possible date to address the fol lowing issue(s): a.Mo�on to Terminate Temporary Compensa�on. b. Objec�on to Termina�on of Temporary Compensa�on. c. Mo�on to Appoint an Independent Medical Examiner. d. Employer Objec�on to Claimant’s Request for Change of Physician. e. Mo�on to Consolidate. LIST ALL COMMISSION FILE NUMBERS, EXCLUDING THE ONE LISTED ABOVE. _______________ _______________ _______________ __ _____________ f Mo�on to Suspend Proceedings or Bene�ts. g. Mo�on to Add Addi�onal Par�es. Include the name and complete address, including the zip code, of EACH ad di�onal party and INSURER, and the alleged DATE OF INJURY. (Use addi�onal sheets if necessary.) A COPY OF THIS MOTION MUST BE MAILED TO EACH ADDITIONAL PARTY AND INSURER LISTED. ________________________________________ I __________ ______________________________ I _____________________ ____ ________________________________________ I __________ ______________________________ I _____________________ ____ ________________________________________ I __________ ______________________________ I _____________________ ____ h. Media�on Order. (Note: Par�es may pursue media�on by mutual agreement without Commiss ion order.) i. Mo�on to Review Permanent Total Disability Status pursuant to 85A O.S., §45(D). j. Other _______________________________________________ ___________________________________________ (specify). 2. Has an Administra�ve Law Judge previously been assigned by the Commission t o hear all ma�ers rela�ng to the above-cap�oned case? YES NO ASSIGNED ADMINISTATIVE LAW JUDGE: ______________________________ ________________________. THE PARTY REQUESTING THIS PREHEARING CONFERENCE HEREBY CERTIFIES THAT THE PARTIES HAVE CONFERRED OR ATTEMPTED TO CONFER IN GOOD FAITH, BUT HAVE REACHED AN IMPASSE AND ARE UNABLE TO R ESOLVE THE ISSUE WITHOUT THE COMMISSION’S ASSISTANCE. 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 material informa�on, or w ho employs any device, scheme, or ar��ce, or who a ids 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. The undersigned declare under PENALTY OF PERJURY that they have examined all statements contained herein, and to the best of their knowledge and belief, they are true, correct and complete. Signed this ____________day of _________________, __________. I HEREBY CERTIFY THAT A COPY HAS BEEN SENT TO: Opposing Party/Counsel Address (Number and Street) City State Zip Code Signature of Reques�ng Party Address City State Zip Code Telephone Number of Reques�ng Party Print or type name of A�orney OBA # Revised 4-18-18 THIS SPACE FOR COMMISSION USE ONLY Addi�onal Party & Address, including City/State/Zip Insurer & Address, including City/State/Zip Alleged Date of Injury