Certificate To Compromise Settlement
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Certificate To Compromise Settlement Form. This is a Oklahoma form and can be use in Workers Comp.
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Tags: Certificate To Compromise Settlement, Oklahoma Workers Comp,
Before the Workers’ Compensation Court of the State of Oklahoma
In re claim of:
Claimant
Respondent
Insurance Carrier
)
)
)
)
)
)
)
WCC File
Number:
Claimant’s Social
Security Number XXX-XX-______________
(LAST 4 DIGITS ONLY)
CERTIFICATE TO COMPROMISE SETTLEMENT
1.
The claimant certifies that the Respondent has been notified of all medical providers who
have provided medical treatment, including physical therapy, as a result of the accidental
injury while employed by Respondent. A list of all medical providers who have provided
treatment is attached hereto as Exhibit A.
Further, the Claimant represents and agrees to notify all future medical providers for the
accidental injury while employed by the Respondent that the claim against the Respondent
has been fully settled by Compromise Settlement.
Claimant
2.
The Respondent’s attorney certifies that a copy of the Compromise Settlement will be
provided to all known medical providers, including physical therapists, who have provided
treatment to the claimant, within ten (10) days of the settlement. The Respondent’s attorney
shall also notify the medical providers that the Compromise Settlement specifies that the
Respondent will not be responsible for treatment rendered after the date of the Compromise
Settlement.
Respondent
- over 08/26/11
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EXHIBIT “A” TO CERTIFICATE TO COMPROMISE SETTLEMENT
The following Medical Providers have provided medical treatment, including physical therapy, as a
result of the accidental injury while employed by Respondent:
Name
Address,
City
State
Zip
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