FORM 100 Send original + 3 copies to Court of Existing Claims In re claim of: Full Name of Claimant (Injured Employee) Claimant's Social Security Number (LAST 4 DIGITS ONLY) XXX-XX-_________________________ Name of Employer (Respondent) COURT OF EXISTING CLAIMS 1915 NORTH STILES, STE 127 OKLAHOMA CITY, OKLAHOMA 73105-4918 THIS SPACE FOR COURT USE ONLY CLAIMANT'S APPLICATION AND ORDER FOR DISMISSAL WCC FILE NO. Employer's Insurance Carrier, Permit # for Court Approved Individual Self-insured or Own Risk Group Date of Injury The claimant moves to DISMISS the above referenced claim pursuant to 85 O.S. § 319, and in support thereof, states: YES _______ _______ NO _______ _______ Please mark the appropriate YES/NO response to the left of each numbered question. 1. The filing fee of $140.00 has been paid and a receipt evidencing payment is attached to this application. (Payment of the fee is required to effect the dismissal. 85 O.S., §319.) 2. The claimant is represented by counsel. 3. A permanent total disability order, permanent partial disability/permanent partial impairment order, or _______ _______ Settlement Agreement has been entered. (An order of dismissal is permissible at any time before final submission of the case to the Court for decision. 85 O.S., §319.) 4. This request is for a dismissal with prejudice. (Prior to entering an order for dismissal with prejudice, the Court may require an evidentiary hearing.) _______ _______ Note: If a workers' compensation claim is timely filed and then dismissed without prejudice, the claim may be refiled within one (1) year from the date the Order of Dismissal Without Prejudice is filed, even if the limitations period has run. I declare under penalty of perjury that I have examined all statements contained herein and they are true, correct and complete, to the best of my knowledge and belief. Any person who commits workers' compensation fraud, upon conviction, shall be guilty of a felony. I HEREBY CERTIFY THAT A COPY HAS BEEN SENT TO: Opposing Party(ies) Address (Number & Street) City Claimant Address (Number & Street) City Telephone # of Claimant State Zip Code State Zip Code Signed this ___________ day of _____________________, _________ Signature of Claimant Print or type name of Attorney for Claimant Signature of Attorney of Claimant OBA # IT IS THEREFORE ORDERED, for good cause shown, that the above captioned claim is dismissed : _______ With Prejudice ________ Without Prejudice The filing of this order does not adjudicate the rights of any health care provider that has provided reasonable and necessary medical care to the claimant for a work related injury. BY ORDER OF __________________________________________________ Rev. 06/24/2015 ________________________ Date of Order American LegalNet, Inc. www.FormsWorkFlow.com