Before the Court of Existing Claims of the State of OklahomaBefore the Court of Existing Claims of the State of OklahomaBefore the Court of Existing Claims of the State of OklahomaBefore the Court of Existing Claims of the State of Oklahoma In re claim of: Claimant ) WCC File ) Number: ) Respondent ) ) ) Claimant222s Social Insurance Carrier ) Security Number XXX-XX- (LAST 4 DIGITS ONLY) 001002003004005006005001007004002b004tb001tn013003tn005f002bf002004004r002n002016004 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 Respondent222s 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 Respondent222s 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 - C. 02/01/14 American LegalNet, Inc. www.FormsWorkFlow.com EXHIBIT 223A224 TO CERTIFICATE TO COMPROMISE SETTLEMENTEXHIBIT 223A224 TO CERTIFICATE TO COMPROMISE SETTLEMENTEXHIBIT 223A224 TO CERTIFICATE TO COMPROMISE SETTLEMENTEXHIBIT 223A224 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: NameNameNameName Address, City State ZipAddress, City State ZipAddress, City State ZipAddress, City State Zip American LegalNet, Inc. www.FormsWorkFlow.com