WORKERS’ COMPENSATION COURT 1915 NORTH STILES OKLAHOMA CITY, OK 73105-4918 Send original and 6 copies to the Workers’ Compensation Court THIS SPACE FOR COURT USE ONLY In re Claim of: (Please type or Print ALL information legibly in ink.) Full Name of Claimant (Injured Employee) Claimant’s Social Security Number COMPROMISE SETTLEMENT - FORM 1X Name of Respondent (Employer) File Number Employer’s Insurance Carrier, Permit # for Court Approved Individual SelfInsured or Own Risk Group, Uninsured Date of Injury We, the above named parties, agree to a compromise settlement of this case based on the following facts and agree to pay and accept compensation as provided herein: 1. The claimant on or about _____________________, ________ was an employee of the respondent, engaged in employment subject to and covered by the Workers’ Compensation Act, with an average weekly wage of $_____________________. 2. Claimant alleges that on or about said date claimant sustained an accidental injury arising out of and in the course of employment with the employer sustaining injury to (list body parts) ________________________________________________________________________________________________. 3. That as a result of said injury claimant was temporarily totally disabled from ____________________, _______ to _____________________, ______ or for a period of ________ weeks, for which claimant received $__________________ in compensation from the respondent or insurance carrier. 4. Claimant is not, nor was previously, represented by an attorney in the claim. 5. Respondent has filed an Employer’s First Notice of Injury (Form 2) for said injury. 6. Claimant agrees to accept the sum of $____________________, in settlement of this claim against the respondent and insurance carrier. Claimant agrees this is a full, final and complete compromise settlement for statutory medical aid, for rehabilitation procedures, and for compensation, including compensation for temporary disability, permanent disability, the benefits of physical and vocational rehabilitation or loss of wage earning capacity which the claimant now has or may hereafter have as a result of any and all injuries sustained in the accident. It is further agreed that said sum is in addition to any sum(s) previously paid to the claimant and in addition to the authorized, reasonable and necessary medical and rehabilitation expenses previously incurred by the claimant resulting from the accidental injury. 7. The respondent or insurance carrier shall pay court costs in the amount of $140.00, in each case, unless the Court cost was previously paid; and the Special Occupational Health and Safety Tax in the sum of $_________________________, representing three-fourths of one percent (0.75%) of the compromise settlement amount. 8. The respondent, if OWN RISK, shall also pay the sum of $_________________, representing 2% of the compromise settlement amount to the Workers’ Compensation Administration Fund and the sum of $___________________, representing 1% of the compromise settlement amount to the appropriate SelfInsured Guaranty Fund, if applicable by law. In addition to other amounts, the respondent, if UNINSURED, shall pay a Multiple Injury Trust Fund assessment in the sum of $___________________, representing 5% of the compromise settlement amount. This compromise settlement is submitted to the Workers’ Compensation Court for approval as provided by law and it is understood that this compromise settlement shall be null and void unless approved by the Workers’ Compensation Court. I declare under penalty of perjury that I have examined 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 ____________________________________________________________ Signature of Claimant ____________________________________________________________ Address of Claimant ________________________________________________________ Name of Respondent ________________________________________________________ Name of Insurance Carrier or Own Risk Group ________________________________________________________ Type or Print Name of Respondent/Insurer Attorney OBA# ________________________________________________________ Signature of Respondent/Insurer Attorney ORDER APPROVING COMPROMISE SETTLEMENT NOW on this _____ day of __________________, ______, the Workers’ Compensation Court having reviewed the evidence, the files and records in this cause and being fully advised in the premises, finds that the above Compromise Settlement, incorporated herein and made a part hereof by reference, should be and is hereby approved. IT IS FURTHER ORDERED, that within 20 days from the filing date of this order, respondent or insurance carrier shall comply herewith, whereupon this cause shall be fully and finally closed and the Court divested of further jurisdiction herein. copy hereof was mailed by United States regular mail on this file-stamped date to all attorneys of record and to unrepresented parties. A Reporter’s Initials Rev. 11/10 BY ORDER OF ___________________________________________ American LegalNet, Inc. www.FormsWorkFlow.com