Oklahoma Workers' Compensation Commission

23112312
CC-Form-4 Report of Compensation Paid/Suspension of Payments
CC-Form-4 Report of Compensation Paid/Suspension of Payments
* Indicates Required Field
OKLAHOMA WORKERS' COMPENSATION COMMISSION 1915 N STILES AVENUE OKLAHOMA CITY, OK 73105 (405)522-5308 OR IN STATE TOLL FREE (855)291-3612 Send copy to Employee or Beneficiaries
*Type of Report Closing Report Amended Report
Commission File Number
Carrier Claim Number
*Full Employee Name (Last, First, MI)
*Employee Social Security Number (Last 4 digits only)
*Employer Name
*City
*State
*Zip Code
*Carrier or Self-Insured Name
Claims Office Location
DISABILITY INFORMATION
*Date of Injury (Format: mm/dd/yyyy)
Last Day Employee Worked (Format: mm/dd/yyyy)
Date Employee Able to Return to Work (Format: mm/dd/yyyy)
Return to Work (RTW) Date (Format: mm/dd/yyyy)
Total Days Worked Between Injury and date able to RTW
TTD Rate:
COMPENSATION INFORMATION Compensation Payments Made: Grand Total field and one other field must be completed
TTD
Weeks
Days
Amount (no commas and no $ sign e.g. 2222.00) $
TPD
Weeks
Days
Amount (no commas and no $ sign e.g. 2222.00) $
PPD
Weeks
Days
Amount (no commas and no $ sign e.g. 2222.00) $
Weeks PTD
Amount (no commas and no $ sign e.g. 2222.00) $
Weeks for Death
Amount (no commas and no $ sign e.g. 2222.00) $
Lump Sum Payment (no commas and no $ sign e.g. 2222.00) $
Joint Petition Settlement (no commas and no $ sign e.g. 2222.00) $
Claimant Attorney Fees (no commas and no $ sign e.g. 2222.00) $
Defense Attorney Fees (no commas and no $ sign e.g. 2222.00) $
Other (Compensation Related) (no commas and no $ sign e.g. 2222.00) $
Hospital Expenses (no commas and no $ sign e.g. 2222.00) $
Medical Expenses (no commas and no $ sign e.g. 2222.00) $
Drugs, Medicine (no commas and no $ sign e.g. 2222.00) $
Funeral Expenses (no commas and no $ sign e.g. 2222.00) $
Rehabilitation (no commas and no $ sign e.g. 2222.00) $
Other (Expense Related) (no commas and no $ sign e.g. 2222.00) $
*Grand Total (no commas and no $ sign e.g. 2222.00) $
SUSPENSION OF PAYMENTS OF COMPENSATION
Date of Suspension of Compensation (Format: mm/dd/yyyy)
Reason for Suspension
Compensation Paid Through (Format: mm/dd/yyyy)
CERTIFICATION
I certify under PENALTY OF PERJURY that the foregoing is a complete and accurate report according to the records of the insurer pertaining to payments of compensation and suspensions of payment information. I further certify that a copy of this report or equilvalent information has been provided to the employee or beneficiaries.
*Printed or Typewritten Name
Title
Signature Date
QUESTIONS ABOUT THE CC-FORM-4, OR GENERAL INFORMATION OR ASSISTANCE ON COMPLETING OR FILING A CC-FORM-4, MAY BE DIRECTED TO THE WORKERS' COMPENSATION COMMISSION COUNSELOR DIVISION, (405) 522-5308 OR IN STATE TOLL FREE (855) 291-3612.
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CC-Form-4 Report of Compensation Paid/Suspension of Payments