Fill and Sign the Records Department Oklahoma Workers Compensation Form

Revised 09/15 This space for Commission Use only WORKERS’ COMPENSATION COMMISSION 1915 NORTH STILES AVE OKLAHOMA CITY, OK 73105 405 -522 -3222 CC-FORM -7 DESIGNATION OF SERVICE AGENT Any person who commits workers’ compensation fraud, upon conviction, shall be guilty of a felony punishable by imprisonment, a fine, or both. The following entities must designate a single agent for service of notice by filing this Designation of Service Agent form with the Commission: insurance carriers; indiv idual own-risk employers; group self -insurance associations ; and qualified employers . Consistent with Workers’ Compensation Commission Rule 810:10- 1-11, once a claim for compensation (CC -Form -3, CC - Form -3A or CC -Form -3B) is filed, the Commission will send all notices and correspondence to the designated agent, until an entry of appearance or a notice of substitution of attorney is filed as provided in Commission Rules 810:10- 1-10 or - 11. The following information is required and must be amended whenever a change of service agent is made. Please check ( ) the appropriate box below: □ Carrier □ Individual Own Risk Employer □ Group Self -Insurance Association □ Qualified Employer (If this service agent designation applies to the entity’s subsidiaries, attach a list of the applicable subsidiaries and/or affiliates , including addresses .) _______________ ________________________________________ ____________________________________ Entity Name Entity Phone Number _______________________________________________________ ___________________________________ Name of contact person Contact Email ______________________________________________________________________________________________ Home Office Mailing Address City State Zip ______________________________________________________________________________________________ Street Address (if different): City State Zip Designated Service Agent Information: _______________________________________________________ ____________________________________ Agent Name Agent Phone Number _______________________________________________________ ___________________________________ Name of contact person if the service agent is a business Agent Email ______________________________________________________________________________________________ Home Office Mailing Address City State Zip ______________________________________________________________________________________________ Street Address (if different): City State Zip ____________________________________________ __________________________________________________ Signature of Entity Representative Printed Name of Entity Representative ____________________________________________ ___________________________________________________ Date Signed Title of Entity Representative