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Electronic Forms

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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 paraEmpresarios y Trabajadores
CC - Form 3	Employee's First Notice of Claim for Compensation *Note: This is not a first report of injury. Consider contacting your insurance company to make a First Report of Injury before you file a claim via CC-Form 3.
CC - Form 3A	Claimant's First Notice of Death and Claim for Compensation
CC - Form 3B	Employee's First Notice of Occupational Disease and Claim for Compensation
CC - Form 3F	Employee's Notice of Claim for Benefits From the Multiple Injury Trust Fund
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 13	Request for Prehearing Conference
CC - Form 17	Physician Disclosure Statement
CC - Form 20	Proof of Loss (Death Claim)
CC - Form 36A	Affidavit of Exempt Status Fill Out and File Your Affidavit of Exempt Status Online
CC - Form 36C	Cancellation of Affidavit of Exempt Status
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 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 - Form
Form - SI LOC	Letter of Credit- Form
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
Request For Prior Claims and Copy Request Form	Prior Claims Request and Copy Request
Subpoena(OKC)
Subpoena (Tulsa)
Certificate of Readiness

(All Forms submitted to the Commission shall be in black print on white paper. Please do not use colored forms.)

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