Fill and Sign the Labor Oklahoma Department of Odol Okgov Form

Date of Accidental Injury Time: ______________ AM PM Place of Injury: City/County/State Date of Death Time: ______________ AM PM Place of Death: City/County/State Nature of Injury Body part(s) injured Describe ac�vi�es when injury occurred, with details of how event occurred. Inc lude object or substance which directly injured deceased. Cause of death (normally shown on Death Cer��cate) Has deceased �led a claim for compensa�on regarding this accident? YES NO CC-FORM -3A USE FOR DEATHS OCCURRING ON OR AFTER FEBRUARY 1, 2014 Send original and 4 copies to: Workers’ Compensa�on Commission IN THE MATTER OF THE DEATH OF (deceased employee) Name of Claimant (individual �ling claim) Name of Employer Commission Use Only CLAIMANT’S FIRST NOTICE OF DEATH AND CLAIM FOR COMPENSATION COMMISSION FILE NO. NOTE: Mediation is available to help resolve certain workers' compensation disputes. F or information, call (405) 522-5308 or in-state toll free (855) 291- 3612. (Please type or print) FULL NAME OF DECEASED EMPLOYEE (Last, First, Middle): Social Security Number (LAST 5 DIGITS ONLY) XXX -X ________________________ Phone: ( ) Mailing Address (include City, State & Zip): Date of Birth: Age: Sex: Occupa�on: Was deceased employment agreement made in Oklahoma? YES NO Average Weekly Wage: Employer: Federal ID# Telephone: Complete Mailing &/or Street Address: City: State: Zip: The undersigned declare under PENALTY OF PERJURY that they have examined this No�ce of Death and Claim for Compensa�on , and all statements contained herein are true, correct and complete, to the best of their knowledge and belief. Signed this ___________ day of____________________________ ____, ___________. Type or Print Name of A�orney: OBA # Mailing Address: City State Zip Telephone #: ( ) Name of Claimant’s A�orney, if represented: Revised 4-18-18 Claimant’s Name (Last, First, Middle): Phone: ( ) Mailing Address (include City, State & Zip): Rela�onship to Deceased Please check appropriate box I. Original Filing II. Amends Previously Filed CC -Form -3A. (Highlight the change and iden�fy whether it adds to or replaces the prior informa�on.) THIS SPACE FOR COMMISSION USE ONLY Signature of A�orney for Claimant (if any) Signature of Claimant (Must be signed by Claimant) WORKERS’ COMPENSATION COMMISSION 1915 NORTH STILES AVENUE STE 231 OKLAHOMA CITY, OK 73105 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 who employs any device, scheme, or ar��ce, or w ho aids and abets any person for the purpose of: (1) obtaining any bene�t or payment … shall be guilty of a felo ny.” Any person who commits workers’ compensa�on fraud, upon convic�on, shall be gui lty of a felony punishable by imprisonment, a �ne or both. Has a personal representa�ve been appointed for the estate of the deceased? YES NO If yes, state name and address of the personal representa�ve b elow: List, on the reverse side of this form, the names, rela�onships, addresses and dates of birth of all persons who were actually dependent upon the deceased at the �me of death. List person or en�ty (with address, phone number) which has paid bene�ts u nder a group health, disability or loss of income policy for the injury reported on this form:_____________________________________________ ______________________________________________________________________