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Individual Self-Insured Employer Worksheet For Calculation of Actual Paid Losses
Use this form to submit your actual paid losses for the calendar year 2023 to the Permitting Services Department of the Oklahoma Workers' Compensation Commission. You may also Print this form and submit by mail to: Workers' Compensation Commission Permitting Services Division 1915 N. Stiles Ave OKC OK 73105-4918 PRINT A COPY FOR YOUR RECORDS BEFORE YOU SUBMIT!
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Indicates Required Field
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Name of Individual Self-Insured Employer
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Oklahoma Own Risk Number
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Calendar Year of Paid Losses
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Medical
:
Includes payment to physicians and other health care providers, including hospitals and payment for diagnostic tests, drugs, prosthetic devices, and rehabilitation services, and such other medical related costs (e.g. travel expenses paid to a worker to secure medical treatment) not otherise exempt from actual paid losses as a loss adjustment.
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Temporary Disability:
Includes Temporary Total Disability (TTD) and Temporary Partial Disability (TPD)
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Permanent Total Disability (PTD)
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Permanent Partial Disability (PPD)
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Death
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Total Actual Paid Losses For Calendar Year
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