Fill and Sign the Workers Compensation Court of Existing Claims 1915 N Stiles Form

CC-FORM -2 Applicable to Injuries /Deaths Occurring On or A�er 2/1/14 Send original to Workers’ Compensa�on Commission and 1 copy to Insurance Carrier Please type or print. Enter all dates in MM/DD/YY format. WORKERS’ COMPENSATION COMMISSION 1915 NORTH STILES AVENUE STE 231 OKLAHOMA CITY, OK 73105 EMPLOYER’S FIRST NOTICE OF INJURY THIS SPACE FOR COMMISSION USE ONLY Employee’s Social Security Number (LAST 4 DIGITS ONLY) XXX -XX -________________________ Average Weekly Wage Telephone Number Occupa�on (job descrip�on) Sex Full Name of Employee - LAST, FIRST, MIDDLE Complete Address City State Zip Date of Birth Was employment agreement made in Oklahoma? YES  NO  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. Date of accident or last exposure Length of Employment: Years Months _______ Date of Hire:__________________________________ Time of accident or exposure o’clock AM  PM  Date Employer No��ed Time workday began o’clock AM  PM  Last date employee worked Has employee returned to work? YES  NO  If yes, on what date ? __________________________ Did the employee die? YES  NO  If yes, on what date ?__________________________________________ Place of Accident or Occurrence City: County: State: Injury Resulted from: Single Incident  Cumula�ve Trauma  Occupa�onal Disease  Nature of Injury or Illness Describe ac�vi�es when injury occurred with details of how even t occurred. Include object or substance which directly inju red the employee. Iden�fy part(s) of body involved in injury or illness Full Name and address of Trea�ng Physician (please be complete) Employer’s Insurance Carrier or Own Risk Group Policy/Self-Insured Number Name Phone Policy Period: From To Address City State Zip Type of business (Example: manufacturing, food service, const ruc�on) NAICS Number Employer’s Name and Complete Address Name Federal ID# Phone # Address City State Zip Type of Ownership: Private  State Government  County Government  Local Government  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 mat erial informa�on, 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 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. Signed Signature of Preparer By Name and Title of Preparer (Please Print) Telephone Number Area Code and Number Date The undersigned hereby declares under PENALTY OF PERJURY that they have examined this no�ce and all statements contained herein are true, correct and complete, to the best of their knowledge. The undersigned cer��es this CC -Form 2 was sent to the Workers’ Compensa�on Commission and a copy thereof to the employer’s insurer on the date noted below: A CC-Form 2 must be sent to the Workers’ Compensa�on Commission and to the employer’s workers’ compensa�on insurance carrier within 10 days a�er the date of receipt of no�ce or knowledge of death or injury that results in more than three days’ absence from work for the injured employee. PROVIDING THIS FORM TO THE COMMISSION IS NOT EVIDENCE OF ANY FACT STATED IN THE REPORT IN ANY PROCEEDING WITH RESPECT TO THE INJURY OR DEATH ON ACCOUNT OF WHICH THE REPORT IS MADE. Does employee par�cipate in a cer��ed workplace medical plan: YES  NO  If yes, name of CWMP: OSHA Log Case # Employee Email Address Revised 2-2 -16