Fill and Sign the Locations Ampamp Maps Oklahoma Workers Compensation Court Form

Are you a previously impaired person due to a prior workers’ compensa�on injury or obvious and apparent pre-exis�ng disability? _______ If “YES”, you may be en�tled to bene�ts for combined disabili�es from the Mul�pl e Injury Trust Fund. A claim for bene�ts for combined disabili�es against the Mul�ple Injury Trust Fund may be commenced by �ling a “CC -Form -3F” with the Workers’ Compensa�on Commission. 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. (Please type or print) CC-FORM -3B USE FOR OCCUPATIONAL DISEASE/ILLNESS OCCURRING ON OR AFTER FEBRUARY 1, 20 14 Send original and 4 copies to: Workers’ Compensa�on Commission WORKERS’ COMPENSATION COMMISSION 1915 NORTH STILES AVENUE STE 231 OKLAHOMA CITY, OK 73105 EMPLOYEE’S FIRST NOTICE OF OCCUPATIONAL DISEASE AND CLAIM FOR COMPEN SATION THIS SPACE FOR COMMISSION USE ONLY Commission use only Full Name of Claimant (Injured Employee) Name of Employer COMMISSION FILE NO. Please check appropriate box I. Original Filing II. Amends Previously Filed CC -Form -3B. (Highlight the change and iden�fy whether it adds to or replaces the prior informa�on.) mation, call (405) 522-8760 or (800) 522- 8210. FULL NAME OF EMPLOYEE (Last, First, Middle): Social Security Number (LAST 5 DIGITS Phone: ONLY): ( ) NOTE: A voluntary Mediatio n Program to address certai n workers’ compensation h the Wo rkers’ Comp ensation Court. For infor- Mailing Address (include City, State & Zip): Date of Birth: Age: Occupa�on: Sex: Was your employment agreement in Oklahoma? YES NO  Avg. Weekly Wage: Length of Employment: Years ______Months_______ Date of hire: __________________________ Date of last exposure to hazard which caused disease: Date of �rst dis�nct manifesta�on: Place of Injury: City/County/State Nature of Disease (example: Reduced breathing capacity or loss of vision) Body Part(s) Injured: Describe how you were exposed to the disease with details of how event occurred. Include object or substance which directly injured you: Employer: Employer’s FEI # (Federal ID Number): Telephone: Complete Mailing Address: City: State: Zip: Complete Street Address (if di�erent from above): City: State: Zip: 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�o n, 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 b e guilty of a felony.” 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. The undersigned declare under PENALTY OF PERJURY that they have examined this No�ce of Occupa�onal Disease and Claim for Compensa�on , and all statements contained herein are true, correct and complete, to the best of their knowledge and belief. Type or Print Name of A�orney: OBA# Mailing Address: City State Zip Telephone #: ( ) Revised 4-18-1 8 Name of Claimant’s A�orney, if represented: Signed this _______________ day of _______________________ ______ , __________ Have you �led a claim for Social Security Disability Insurance Bene�ts? YES  NO  Are you eligible for Medicare Bene�ts or will you become eligible fo r Medicare Bene�ts within 30 months of the �ling of this No�ce of Occupa�onal Disease and Claim fo r Compensa�on? YES NO  Signature of Claimant (Must be signed by Claimant) Signature of A�orney for Claimant (if any) CLAIM INFORMATION (Please Print) Is this a claim for ini�al bene�ts (i.e. no bene�ts, either medical or indemnity, have been received)? □ YES □ NO Is this a claim for addi�onal bene�ts (e.g. addi�onal temporary total disability, addi�onal medical)? □ YES □ NO ___________________________________________________ ___________________________________________________ _______________________ 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:_____________________________________________ ______________________________________________________________________ XXX-X