Electronic Forms

CC-Form-4 Report of Compensation Paid/Suspension of Payments

Forms

Form Number	Title
CC- Form 1A	Oklahoma Workers' Compensation Notice and Instruction to Employers and Employees
CC - Form 1A Spanish	Aviso e Instrucción de Compensación de Trabajadores de Oklahoma para Empresarios y Trabajadores
CC - Form 2	Employer's First Notice of Injury
CC - Form 2A	Employer's Intent to Controvert Claim
CC - Form 2A Extension	Employer's Application and Authorization for Extension of Time to File CC- Form 2A (Email submission is not currently available)
CC - Form 3	Employee's First Notice of Claim for Compensation (Light Blue)
CC - Form 3A	Claimant's First Notice of Death and Claim for Compensation (Cream)
CC - Form 3B	Employee's First Notice of Occupational Disease and Claim for Compensation (Lilac)
CC - Form 3C	Claim for Workers' Compensation Discrimination or Retaliation
CC - Form 3F	Employee's Notice of Claim for Benefits From the Multiple Injury Trust Fund (Gray)
CC - Form 4	Report of Compensation Paid
CC - Form 5	Physician's Report of Release and Restrictions
CC- Form 7	Designation of Service Agent
CC - Form 9	Request for Hearing
CC - Form 10	Answer and Notice of Contested Issues
CC - Form 10A	Respondent's Response to Claimant's Application for Change of Physician
CC - Form 10C	Employer's Response to Claim for Workers' Compensation Discrimination or Retaliation
CC - Form 13	Request for Prehearing Conference
CC - Form 17	Physician Disclosure Statement
CC - Form 20	Proof of Loss (Death Claim)
CC - Form 36	Application for Certificate of Non-Coverage
CC - Form 40	Request for Review of Proposed Judgment
CC - Form 50	Medical Interlocutory Order Request
CC - Form 71	Authorization for Attorney Representation
CC - Form 93	Application and Order for Leave to Withdraw as Attorney of Record
CC - Form 99	Pauper's Affidavit
CC - Form 100	Claimant's Application and Order for Dismissal
CC - Form 211	Request for Review of Adverse Benefit Determination
CC - Form 300	Request for Proceeding Regarding Arbitration Agreement
CC - Form 463	Application for Independent Medical Examiner
CC - Form 626	Medical Case Manager Application
CC - Form 862	Vocational Rehabilitation Services (VRS) Registry Form
CC - Form 926	Application for Appointment as Certified Workers' Compensation Mediator
CC - Form A Order	Order for Change of Treating Physician
CC- Form A	Claimant's Application for Change of Physician and Request for Hearing
CC - Form M	Request for Appointment of Independent Medical Examiner, Rehabilitation Evaluator, or Medical Case Manager
CC - Form V	Verification of Permanent Total Disability
CC - Joint Petition	Joint Petition Settlement
Certificate to Joint Petition
Death Claim Settlement Order
Form JP Appendix	Joint Petition Settlement Appendix
Form - SI Bond	Surety Bond - Sample Form
Form - SI Employer	Application for Individual Own Risk Employer Permit
Form - SI Group	Application for Group Self Insurance Association Permit
Form - SI LOC	Letter of Credit- Sample Form
Form - SI TPA	Application for Third-Party Administrator Permit
Mediation Agreement
Mediation Conference Report
Mediation Request Form
MFDR Form 10M	Response to Provider Request for Medical Dispute Resolution
MFDR Form 19	Provider Request for Medical Fee Dispute Resolution
Notice to Injured Workers
Prior Claims Request - Exempt Requestor
Prior Claims Request - Nonexempt Requestor
Prior Claims Request By Mail- Nonexempt Requestor	Prior Claims Request
Prior Claims Request By Mail With Employer Designation
Subpoena (OKC)
Subpoena (Tulsa)
Copy Request Form
Copier Charge Account Form
Certificate of Readiness

( Note with the exception of Forms 3, 3A, 3B, & 3F the form color is white)

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Last Modified on 05/18/2018