Rule 1.301, Form No. 9 IN THE SUPREME COURT OF THE STATE OF OKLAHOMA ) ) ) ) ) ) ) ) ) ) ) , Petitioner, v. ,and THE WORKERS' COMPENSATION COURT, Respondents. No. PETITION FOR REVIEW A. WORKERS' COMPENSATION COURT HISTORY Number and style of proceeding in the court: ___________________________________ Decision to be reviewed was rendered by: (Check one) ( ( ) The Workers' Compensation Court en banc, or ) A Judge of the Court. Date of filing of the decision to be reviewed? ____________________ Date a copy of the decision was sent to the parties? ____________________ If seeking a review of the decision of the court en banc, also give date of the decision by the trial judge: ____________________, and the date an appeal was brought to the tribunal en banc: ____________________ (Otherwise mark N/A). B. DISPOSITION IN THE WORKERS' COMPENSATION COURT Nature of the decision to be reviewed ____________________________________ Relief sought: ______________________________________________________ Relief granted: _____________________________________________________ (Attach a certified copy of the decision to be reviewed as exhibit "A".) A copy of the clerk's certificate that the employer has an approved statutory bond on file with the court also is attached hereto ____ Yes ____ No American LegalNet, Inc. www.FormsWorkFlow.com (Required only if review is sought by employer or insurance carrier from a decision awarding benefits to claimant). C. BRIEF SUMMARY OF PROCEEDING Exhibit "B" attached (not to exceed one 8 1/2 x 11" double spaced page). D. ISSUES AND ERRORS PROPOSED TO BE RAISED ON APPEAL Exhibit "C" attached. (Number and state with specificity each point urged as error.) (General assignments will not suffice.) ANY RELATED OR PRIOR APPEALS? ____ YES ____ NO (Identify by style, citation, if any, and Supreme Court Number.) Style _________________________ _________________________ _________________________ Citation _________________________ _________________________ _________________________ Supreme Court No. _________________________ _________________________ _________________________ E. ATTORNEY FOR PETITIONER Name:______________________________ Firm: _______________________________ Address: ____________________________ ____________________________________ Telephone: __________________________ ATTORNEY FOR RESPONDENT Name: :______________________________ Firm: _______________________________ Address: ____________________________ ____________________________________ Telephone: __________________________ (Give the name and address of the party if unrepresented) Date: __________________, 20____ Verified by (Signature of Attorney or Pro Se Party) OBA No. Firm Designated Case-Specific Email Address [if applicable] Secondary Email Address [if applicable] Address Telephone American LegalNet, Inc. www.FormsWorkFlow.com CERTIFICATE OF FILING AND MAILING I ___________________________, do hereby certify that on this _____ day of _________, 20_____, I did cause to be filed with the Workers' Compensation Court, a correct copy of the Petition for Review with attachment(s), and also mailed a copy with attachment(s) to each party to the proceeding or his counsel of record as follows: [Names and addresses of all parties or counsel of record] American LegalNet, Inc. www.FormsWorkFlow.com