23112312 |
CC-Form-4 Report of Compensation Paid/Suspension of Payments
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CC-Form-4 Report of Compensation Paid/Suspension of Payments
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* Indicates Required Field
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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
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DISABILITY INFORMATION |
(Format: mm/dd/yyyy)
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(Format: mm/dd/yyyy)
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(Format: mm/dd/yyyy)
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(Format: mm/dd/yyyy)
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COMPENSATION INFORMATION
Compensation Payments Made:
Grand Total field and one other field must be completed
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TTD |
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(no commas and no $ sign e.g. 2222.00) $ |
TPD |
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(no commas and no $ sign e.g. 2222.00) $ |
PPD |
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(no commas and no $ sign e.g. 2222.00) $ |
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(no commas and no $ sign e.g. 2222.00) $ |
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(no commas and no $ sign e.g. 2222.00) $ |
(no commas and no $ sign e.g. 2222.00) $ |
(no commas and no $ sign e.g. 2222.00) $ |
(no commas and no $ sign e.g. 2222.00) $ |
(no commas and no $ sign e.g. 2222.00) $ |
(no commas and no $ sign e.g. 2222.00) $ |
(no commas and no $ sign e.g. 2222.00) $ |
(no commas and no $ sign e.g. 2222.00) $ |
(no commas and no $ sign e.g. 2222.00) $ |
(no commas and no $ sign e.g. 2222.00) $ |
(no commas and no $ sign e.g. 2222.00) $ |
(no commas and no $ sign e.g. 2222.00) $ |
(no commas and no $ sign e.g. 2222.00) $ |
SUSPENSION OF PAYMENTS OF COMPENSATION |
(Format: mm/dd/yyyy)
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(Format: mm/dd/yyyy)
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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. |
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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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