WORKERS COMPENSATION COMMISSION 1915 NORTH STILES AVENUE OKLAHOMA CITY, OK 73105 CC-FORM-3A USE FOR DEATHS OCCURRING ON OR AFTER FEBRUARY 1, 2014 Send original and 4 copies to: Workers Compensation.
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How to fill out the What Is Form Cc Form 3a For Ok online
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.
- Press the ‘Get Form’ button to acquire the form and access it in your online editor.
- 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.
- 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.
- Provide the mailing address of the deceased employee, including city, state, and zip code, along with their occupation and date of birth.
- 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.
- Complete the claimant's section by providing their full name, phone number, mailing address, and relationship to the deceased.
- 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.
- 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.
- 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.'
- Provide the employer's name and their federal ID number, along with their complete mailing address.
- Indicate if a personal representative has been appointed for the deceased's estate. If yes, provide their name and address.
- 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.
- List any person or entity that has paid benefits related to the injury reported, including address and phone number.
- Complete the attorney section if applicable, noting the attorney's name and OBA number.
- Once all information is accurately filled out, review the entire form, ensuring all declarations are true and complete.
- 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.
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Get answers to your most pressing questions about US Legal Forms API.
What form is used to file a workers compensation claim on behalf of an injured worker in Oklahoma?
A CC-Form 2 must be sent to the Workers' Compensation Commission and to the employer's workers' compensation insurance carrier within 10 days after the date of receipt of notice or knowledge of death or injury that results in more than three days' absence from work for the injured employee.
How do I get workers comp exemption in Oklahoma?
The form is listed under Affidavit of Exempt Status on the Case OK website. The cost for an Affidavit of Exempt Status is $50.00 plus a $1.00 online processing fee. Please note the Workers' Compensation Commission will not accept checks for the Affidavit of Exempt Status Fee.
Do you have to have workers comp in Oklahoma?
Responsibilities prior to a work injury occurring Every employer, with a few exceptions, is required by law to carry workers' compensation insurance, or "secure compensation" for its employees, as defined by law.
Does LLC need workers comp insurance in Oklahoma?
The law states that nearly every employer is required to carry workers' compensation coverage. In some circumstances, certain employees in Oklahoma may be exempt from workers' comp coverage, such as: Sole proprietors. Members of a limited liability company (LLC) who own at least 10% of the capital.
Is there a waiting period for workers comp in Oklahoma?
To be eligible for wage benefits, the injured employee must be deemed disabled by a physician and must not have worked for a minimum of three (3) days. Waiting Period: There is a three-day waiting period in Oklahoma.
What are my rights with workers comp in Oklahoma?
When you are injured on the job and you are unable to work for more than 7 calendar days, you are eligible for weekly benefits amounting to 70% of your average weekly wage, up to the maximum set by law. The maximum is equal to the state's average weekly wage.
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