FORM 3A Send original and 4 copies to Court of Existing Claims COURT OF EXISTING CLAIMS 1915 NORTH STILES, STE 127 OKLAHOMA CITY, OK 73105-4918 Please check appropriate box I. Original Filing II. Amends Previously Filed Form 3A (Must clearly state whether amendment is in addition to, or substitute for, prior information.) THIS SPACE FOR COURT USE ONLY IN THE MATTER OF THE DEATH OF (deceased employee) Name of Claimant (individual filing claim) Name of Employer Court Use Only CLAIMANT'S FIRST NOTICE OF DEATH AND CLAIM FOR COMPENSATION WCC FILE NO. NOTE: Mediation is available to address certain workers' compensation disputes. (Please type or print) DECEASED EMPLOYEE NAME (Last, First, Middle): Mailing Address (include City, State & Zip): Occupation: Claimant's Name (Last, First, Middle): Mailing Address (include City, State & Zip): Date of Accidental Injury Date of Death Nature of Injury Time: ______________ AM Time: ______________ AM Place of Injury: PM Place of Death: PM Body part(s) injured City/County/State For information, call (918) 581-2714. Social Security #: Date of Birth: Was deceased employment agreement made in Oklahoma? YES NO Phone: ( ) Age: Average Weekly Wage: Phone: ( Sex: ) Relationship to Deceased City/County/State Describe activities when injury occurred, with details of how event occurred. Include object or substance which directly injured deceased. Cause of death (normally shown on Death Certificate) Employer: Complete Mailing &/or Street Address: Has a personal representative been appointed for the estate of the deceased? Has deceased filed a claim for compensation regarding this accident? YES NO Federal ID# City: YES NO Telephone: State: Zip: If so, state the name and address below. ________________________________________________________________________________________________________________________________ List names, relationships, addresses and dates of birth of all heirs at law of deceased and any other person who actually depended upon deceased at the time of death. (on the reverse side) Any person who commits workers' compensation fraud, upon conviction, shall be guilty of a misdemeanor. Name of claimant's attorney if represented: Type or Print Name of Attorney: Mailing Address: City Telephone #: ( ) State Zip OBA # Upon filing this Notice of Death And Claim For Compensation, permission is given to the Administrator of the Court of Existing Claims, the Insurance Commissioner, the Attorney General, a District Attorney or their designees to examine all records relating to the notice, any matter contained in the notice, and any matter related to the notice. The permission to the above persons authorizes them access to medical records pursuant to 76 O.S., §19, including waiver of any privilege granted by law concerning communications made to a physician or health care provider or knowledge obtained by such physician or health care provider by personal examination. I declare under penalty of perjury that I have examined this Notice of Death and Claim for Compensation, and all statements contained herein are true, correct and complete, to the best of my knowledge and belief. Signed this ______________ day of_____________________, ___________ Signature of Attorney for Claimant Signature of Claimant (must be signed by claimant) American LegalNet, Inc. www.FormsWorkFlow.com Rev. 06/24/2015