"Request Form for Claims File Information/Prior Claims" - Oklahoma

Request Form for Claims File Information/Prior Claims is a legal document that was released by the Oklahoma Court System - a government authority operating within Oklahoma.

Form Details:

  • Released on January 13, 2015;
  • The latest edition currently provided by the Oklahoma Court System;
  • Ready to use and print;
  • Easy to customize;
  • Compatible with most PDF-viewing applications;

Download a fillable version of the form by clicking the link below or browse more documents and templates provided by the Oklahoma Court System.

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Download "Request Form for Claims File Information/Prior Claims" - Oklahoma

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REQUEST FOR CLAIMS FILE INFORMATION/PRIOR CLAIMS
Please complete this form and return it to the following address, together with all appropriate documents and a pre-addressed
stamped envelope. This request will NOT be processed if the self-addressed stamped envelope is not provided. Applicable
search fees ($1 per search conducted) and copy charges apply.
WORKERS’ COMPENSATION COURT
of EXISTING CLAIMS
1915 N. Stiles Avenue, Suite 127
Oklahoma City, OK 73105-4918
(405) 522-8600
**********************************************************************************************************
Please indicate
the TYPE
of search you are requesting (please type or print):
By Name
By Name and the LAST 4 DIGITS of the Social Security Number
(Authorization from the holder of the Social Security Number is
required.)
First Name
First Name
Last Name
I authorize the use of my Name and the LAST 4 DIGITS of my Social Security
Last Name
Number to search for workers’ compensation information as evidenced by my
signature below:
Signature of SSN Holder:
Date
Social Security #: LAST 4 DIGITS ONLY
XXX-XX-____________________________________
I declare under PENALTY OF PERJURY that the information sought hereby is not for a purpose in
violation of any state or federal law. I understand that I am required by law to disclose the person for whom
this search request is being made, if different from myself.
This search is being made on behalf of the following:
Name: _________________________________________________________________
Address : _______________________________________________________________
City: _______________________________ State: _____ Zip Code: ______________
Please indicate your information below (the preparer of this form):
Preparer's Signature
Preparer’s Printed Name:
Telephone #
Address:
City:
State:
Zip Code:
This document is considered a public record under Oklahoma law.
Revised 1/13/15
REQUEST FOR CLAIMS FILE INFORMATION/PRIOR CLAIMS
Please complete this form and return it to the following address, together with all appropriate documents and a pre-addressed
stamped envelope. This request will NOT be processed if the self-addressed stamped envelope is not provided. Applicable
search fees ($1 per search conducted) and copy charges apply.
WORKERS’ COMPENSATION COURT
of EXISTING CLAIMS
1915 N. Stiles Avenue, Suite 127
Oklahoma City, OK 73105-4918
(405) 522-8600
**********************************************************************************************************
Please indicate
the TYPE
of search you are requesting (please type or print):
By Name
By Name and the LAST 4 DIGITS of the Social Security Number
(Authorization from the holder of the Social Security Number is
required.)
First Name
First Name
Last Name
I authorize the use of my Name and the LAST 4 DIGITS of my Social Security
Last Name
Number to search for workers’ compensation information as evidenced by my
signature below:
Signature of SSN Holder:
Date
Social Security #: LAST 4 DIGITS ONLY
XXX-XX-____________________________________
I declare under PENALTY OF PERJURY that the information sought hereby is not for a purpose in
violation of any state or federal law. I understand that I am required by law to disclose the person for whom
this search request is being made, if different from myself.
This search is being made on behalf of the following:
Name: _________________________________________________________________
Address : _______________________________________________________________
City: _______________________________ State: _____ Zip Code: ______________
Please indicate your information below (the preparer of this form):
Preparer's Signature
Preparer’s Printed Name:
Telephone #
Address:
City:
State:
Zip Code:
This document is considered a public record under Oklahoma law.
Revised 1/13/15