FORM CS-APPENDIX COURT OF EXISTING CLAIMS 1915 NORTH STILES, STE 127 OKLAHOMA CITY, OK 73105-4918 THIS SPACE FOR COURT USE ONLY COMPROMISE SETTLEMENT APPENDIX In re Claim of: Full Name of (Please type or Print ALL information legibly in ink.) Injured Employee Deceased Employee if a Death Claim Social Security Number (LAST 4 DIGITS ONLY) of: Injured Employee Deceased Employee if a Death Claim XXX­ XX-_____________________________ Name of Employer Employer's Insurance Carrier, Permit # for Court Approved Individual Self-Insured or Own Risk Group, Uninsured WCC File Number Date of Injury Date of Death if a Death Claim Use and attach to a Form CS-339(A) or a Form CSD-337 (Death Claim), as applicable, ONLY IF the Compromise Settlement seeks to settle and determine SOME, BUT NOT ALL, issues and matters in the claim. Identify the outstanding issues that are subject to the Court's continuing jurisdiction. NOTE: The original and five (5) copies of the Compromise Settlement with Appendix attached are required when the settlement order is submitted to the Court of Existing Claims for filing. By signing below, each party affirms that they have read and understand the provisions of this COMPROMISE SETTLEMENT APPENDIX, declares under penalty of perjury that all statements are true and accurate to the best of their knowledge and belief, and understands that the Compromise Settlement Appendix, if approved by the Court of Existing Claims, is conclusive, final and binding on all parties involved. Any person who commits workers' compensation fraud, upon conviction, shall be guilty of a felony. _____________________________________________________________________ Name of Claimant X ____________________________________________________________________ Signature of Claimant DATE _____________________________________________________________________ Address of Claimant ____________________________________________________________________ Type or Print Name of Claimant's Attorney, if any OBA# X____________________________________________________________________ Signature of Claimant's Attorney, if any DATE __________________________________________________________________ Name of Respondent __________________________________________________________________ Name of Insurance Carrier or Own Risk Group __________________________________________________________________ Type or Print Name of Respondent/Insurer Attorney OBA# X________________________________________________________________ Signature of Respondent/Insurer Attorney DATE Rev. 06/24/2015 American LegalNet, Inc. www.FormsWorkFlow.com