THIS SPACE FOR COURT USE ONLY WORKERS’ COMPENSATION COURT 1915 NORTH STILES OKLAHOMA CITY, OK 73105-4918 FORM 3A Send original and 4 copies to Workers’ Compensation Court Please check appropriate box I. Original Filing IN THE MATTER OF THE DEATH OF (deceased employee) II. Amends Previously Filed Form 3A (Must clearly state whether amendment is in addition to, or substitute for, prior information.) Name of Claimant (individual filing claim) Name of Employer CLAIMANT’S FIRST NOTICE OF DEATH AND CLAIM FOR COMPENSATION FILE NO. Court Use Only NOTE: Mediation is available to address certain workers' compensation disputes. For information, call (405) 522-8760 or in-state toll free (800) 522-8210. (Please type or print) DECEASED EMPLOYEE NAME (Last, First, Middle): Phone: ( ) Social Security #: Date of Birth: Mailing Address (include City, State & Zip): Claimant’s Name (Last, First, Middle): Phone: ( Place of Injury: City/County/State Place of Death: Time: ______________ AM City/County/State PM Time: ______________ AM Date of Death ) Relationship to Deceased Mailing Address (include City, State & Zip): Date of Accidental Injury Sex: Average Weekly Wage: Was deceased employment agreement made in Oklahoma? YES NO Occupation: Age: PM Body part(s) injured Nature of Injury Describe activities when injury occurred, with details of how event occurred. Include object or substance which directly injured deceased. Has deceased filed a claim for compensation regarding this accident? YES NO Cause of death (normally shown on Death Certificate) Employer: Federal ID# Complete Mailing &/or Street Address: Telephone: City: Has a personal representative been appointed for the estate of the deceased? YES State: NO 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) I declare under penalty of perjury that I have examined this notice and claim, and all statements contained herein, and to the best of my knowledge and belief, they are true, correct and complete. Any person who commits workers’ compensation fraud, upon conviction, shall be guilty of a felony. Name of claimant’s attorney if represented: Type or Print Name of Attorney: OBA # Mailing Address: City State Telephone #: ( ) Zip Upon filing this Notice of Death And Claim For Compensation, permission is given to the Administrator of the Workers’ Compensation Court, the Insurance Commissioner, the Attorney General, a district attorney or their designees to examine all records relating to the notice. The permission granted to the above named individuals or their designees authorizes them access to medical records pursuant to Section 19 of Title 76 of the Oklahoma Statutes, 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. Signed this ______________ day of_____________________, ________ Signature of Attorney for Claimant Signature of Claimant (must be signed by claimant) 2/06 American LegalNet, Inc. www.USCourtForms.com