CC- Form 3F "Employee's Notice of Claim for Benefits From the Multiple Injury Trust Fund" - Oklahoma

What Is CC- Form 3F?

This is a legal form that was released by the Oklahoma Workers Compensation Commission - a government authority operating within Oklahoma. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on April 18, 2018;
  • The latest edition provided by the Oklahoma Workers Compensation Commission;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of CC- Form 3F by clicking the link below or browse more documents and templates provided by the Oklahoma Workers Compensation Commission.

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Download CC- Form 3F "Employee's Notice of Claim for Benefits From the Multiple Injury Trust Fund" - Oklahoma

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CC-FORM-3F
THIS SPACE FOR COMMISSION USE ONLY
WORKERS’ COMPENSATION COMMISSION
1915 NORTH STILES AVENUE
USE FOR SUBSEQUENT INJURY OCCURRING ON OR AFTER
OKLAHOMA CITY, OK 73105
FEBRUARY 1, 2014
Send original to:
Workers’ Compensation Commission and 1 copy to the
Please check appropriate box
Multiple Injury Trust Fund and 1 copy to the Oklahoma
State Treasurer
I. Original Filing
II. Amends Previously Filed CC-Form-3F.
Full Name of Claimant (Injured Employee)
(Highlight the change and identify
whether it adds to or replaces the
prior information.)
MULTIPLE INJURY TRUST FUND
P.O. Box 528801
EMPLOYEE’S NOTICE OF CLAIM FOR BENEFITS FROM THE
Oklahoma City, OK 73152
MULTIPLE INJURY TRUST FUND
OKLAHOMA STATE TREASURER
2300 N. Lincoln Boulevard, Room 217, State Capitol Bldg.
COMMISSION FILE NO.
Oklahoma City, OK 73105
(Please type or print)
(LAST 5 DIGITS ONLY)
Phone:
FULL NAME OF EMPLOYEE (Last, First, Middle)
Social Security #
(
)
XXX-X
Mailing Address (include City, State, & Zip)
Date of Birth:
Age:
Sex:
Date of Injury
Date of Order
Percentage of Disability Awarded and Body Part
Commission File Number for most recent injury
Rate of weekly compensation for permanent partial disability at the
Amount of Joint Petition Settlement or Other Settlement
time of the most recent injury
Amount of Joint Petition
Commission File No.
Date of Injury
Date of Order
% of Disability & Body Part
Settlement or Other Settlement
P
R
I
O
R

Are weekly benefits still being paid on any of the above orders? YES
NO
If so, when are benefits expected to terminate?
List and describe fully any other pre-existing disability for which no award has been made. (Pre-existing disability means any obvious and apparent disability resulting from any
cause, which disability is obvious and apparent from observation of a person who is not skilled in the medical profession.)
Administrative Workers’ Compensation Act, 85A O.S., §6(A)(1)(a): “Any person or entity who makes any material false statement or
representation, who willfully and knowingly omits or conceals any material information, or who employs any device, scheme, or artifice,
or who aids and abets any person for the purpose of: (1) obtaining any benefit or payment … shall be guilty of a felony.”
Any person who commits workers’ compensation fraud, upon conviction, shall be guilty of a felony punishable by imprisonment, a
fine or both.
Name of Claimant’s Attorney, if represented:
The undersigned declare under PENALTY OF PERJURY that they have examined this
Notice of Claim for Benefits from the Multiple Injury Trust Fund and all statements
Type or Print Name of Attorney:
OBA #
contained herein are true, correct and complete, to the best of their knowledge and
belief. Additionally, the undersigned certify that a true and correct copy of this
Notice of Claim was mailed to the MULTIPLE INJURY TRUST FUND and to the
Mailing Address:
OKLAHOMA STATE TREASURER on the date noted below.
Signed this __________day of_______________________________ , _____________.
City:
State:
Zip:
________________________________________________________________________
Telephone #:
Signature of Claimant (Must be signed by Claimant)
(
)
Email:
________________________________________________________________________
Signature of Attorney for Claimant (if any)
Revised 4-18-18
CC-FORM-3F
THIS SPACE FOR COMMISSION USE ONLY
WORKERS’ COMPENSATION COMMISSION
1915 NORTH STILES AVENUE
USE FOR SUBSEQUENT INJURY OCCURRING ON OR AFTER
OKLAHOMA CITY, OK 73105
FEBRUARY 1, 2014
Send original to:
Workers’ Compensation Commission and 1 copy to the
Please check appropriate box
Multiple Injury Trust Fund and 1 copy to the Oklahoma
State Treasurer
I. Original Filing
II. Amends Previously Filed CC-Form-3F.
Full Name of Claimant (Injured Employee)
(Highlight the change and identify
whether it adds to or replaces the
prior information.)
MULTIPLE INJURY TRUST FUND
P.O. Box 528801
EMPLOYEE’S NOTICE OF CLAIM FOR BENEFITS FROM THE
Oklahoma City, OK 73152
MULTIPLE INJURY TRUST FUND
OKLAHOMA STATE TREASURER
2300 N. Lincoln Boulevard, Room 217, State Capitol Bldg.
COMMISSION FILE NO.
Oklahoma City, OK 73105
(Please type or print)
(LAST 5 DIGITS ONLY)
Phone:
FULL NAME OF EMPLOYEE (Last, First, Middle)
Social Security #
(
)
XXX-X
Mailing Address (include City, State, & Zip)
Date of Birth:
Age:
Sex:
Date of Injury
Date of Order
Percentage of Disability Awarded and Body Part
Commission File Number for most recent injury
Rate of weekly compensation for permanent partial disability at the
Amount of Joint Petition Settlement or Other Settlement
time of the most recent injury
Amount of Joint Petition
Commission File No.
Date of Injury
Date of Order
% of Disability & Body Part
Settlement or Other Settlement
P
R
I
O
R

Are weekly benefits still being paid on any of the above orders? YES
NO
If so, when are benefits expected to terminate?
List and describe fully any other pre-existing disability for which no award has been made. (Pre-existing disability means any obvious and apparent disability resulting from any
cause, which disability is obvious and apparent from observation of a person who is not skilled in the medical profession.)
Administrative Workers’ Compensation Act, 85A O.S., §6(A)(1)(a): “Any person or entity who makes any material false statement or
representation, who willfully and knowingly omits or conceals any material information, or who employs any device, scheme, or artifice,
or who aids and abets any person for the purpose of: (1) obtaining any benefit or payment … shall be guilty of a felony.”
Any person who commits workers’ compensation fraud, upon conviction, shall be guilty of a felony punishable by imprisonment, a
fine or both.
Name of Claimant’s Attorney, if represented:
The undersigned declare under PENALTY OF PERJURY that they have examined this
Notice of Claim for Benefits from the Multiple Injury Trust Fund and all statements
Type or Print Name of Attorney:
OBA #
contained herein are true, correct and complete, to the best of their knowledge and
belief. Additionally, the undersigned certify that a true and correct copy of this
Notice of Claim was mailed to the MULTIPLE INJURY TRUST FUND and to the
Mailing Address:
OKLAHOMA STATE TREASURER on the date noted below.
Signed this __________day of_______________________________ , _____________.
City:
State:
Zip:
________________________________________________________________________
Telephone #:
Signature of Claimant (Must be signed by Claimant)
(
)
Email:
________________________________________________________________________
Signature of Attorney for Claimant (if any)
Revised 4-18-18