Get What Is Form Cc Form 3a For Ok

This guide provides clear and comprehensive instructions for filling out the What Is Form Cc Form 3a for Oklahoma online. Whether you are a claimant or a representative, understanding each component of the form is crucial for accurate submission.

Follow the steps to complete the form effectively.

1. Press the ‘Get Form’ button to acquire the form and access it in your online editor.
2. Indicate the filing status by checking the appropriate box at the top of the form. Choose between 'Original Filing' and 'Amends Previously Filed CC-Form-3A,' ensuring to highlight changes if applicable.
3. In the section labeled 'In the Matter of the Death of,' fill in the full name of the deceased employee, followed by their Social Security number (last four digits only) and phone number.
4. Provide the mailing address of the deceased employee, including city, state, and zip code, along with their occupation and date of birth.
5. Answer whether the deceased's employment agreement was made in Oklahoma by selecting 'Yes' or 'No.' Fill in the deceased's age and average weekly wage.
6. Complete the claimant's section by providing their full name, phone number, mailing address, and relationship to the deceased.
7. Fill in the details of the incident, including the date and time of the accidental injury and death, the deceased's sex, place of injury, and place of death.
8. Describe the nature of the injury and the body parts affected. Include detailed information about the activities when the injury occurred, specifying the object or substance that caused the injury.
9. State the cause of death as normally displayed on the death certificate. Indicate if the deceased has previously filed a claim for compensation regarding this accident by selecting 'Yes' or 'No.'
10. Provide the employer's name and their federal ID number, along with their complete mailing address.
11. Indicate if a personal representative has been appointed for the deceased's estate. If yes, provide their name and address.
12. On the reverse side of the form, list the names, relationships, addresses, and dates of birth of all people who were dependent upon the deceased at the time of death.
13. List any person or entity that has paid benefits related to the injury reported, including address and phone number.
14. Complete the attorney section if applicable, noting the attorney's name and OBA number.
15. Once all information is accurately filled out, review the entire form, ensuring all declarations are true and complete.
16. Finally, save the changes, download the completed form, print it, or share it as necessary.

Begin completing your form online today to ensure a timely submission.