Certificate To Joint Petition
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Certificate To Joint Petition Form. This is a Oklahoma form and can be use in Workers Comp.
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Tags: Certificate To Joint Petition, CJP, Oklahoma Workers Comp,
Before the Workers’ Compensation Court of the State of Oklahoma
In re claim of:
Claimant
Respondent
Insurance Carrier
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)
)
)
)
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Court File
Number:
Claimant’s Social
Security Number:
CERTIFICATE TO JOINT PETITION
1.
The claimant certifies that he has notified the Respondent 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 that he/she will notify all future medical
providers for the accidental injury while employed by the Respondent that the claim against
the Respondent has been Joint Petitioned (settled).
Claimant
2.
The Respondent’s attorney certifies that a copy of the Joint Petition 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 Joint Petition Settlement specifies
that the Respondent will not be responsible for treatment rendered after the date of the Joint
Petition.
Respondent
- over 2/06
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EXHIBIT “A” TO CERTIFICATE OF JOINT PETITION
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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