FORM CS-337 WORKERS’ COMPENSATION COURT 1915 NORTH STILES Send original and 5 copies to the Workers’ Compensation Court. OKLAHOMA CITY, OK 73105-4918 IN RE DEATH OF: (Please type or Print ALL information legibly in ink.) THIS SPACE FOR COURT USE ONLY Full Name of Deceased Employee Full Name of Spouse or Dependent or Guardian of Such Person WCC File Number Deceased Employee’s Social Security Number (LAST 4 DIGITS ONLY) Date of Death XXX-XXName of Employer Employer’s Insurance Carrier, Permit # for Court Approved Individual Self-Insured or Own Risk Group, Uninsured Any person who commits workers’ compensation fraud, upon conviction, shall be guilty of a felony. COMPROMISE SETTLEMENT — Section 337 WC Code (Death Claim) This agreement is prepared and submitted pursuant to Section 337 of the Workers’ Compensation Code, Title 85 of the Oklahoma Statutes. By signing below, each party affirms that they have read and understand its provisions, declares under penalty of perjury that all statements are true and accurate to the best of their knowledge and belief, and understands that the agreement, if approved by the Workers’ Compensation Court, is conclusive, final and binding on all the parties involved. By this agreement, the parties settle upon and determine (check one): ALL ISSUES AND MATTERS IN THE CLAIM SOME, BUT NOT ALL, ISSUES AND MATTERS IN THE CLAIM — Attach appendix (Settlement and Resolution of Claim With Full Release) of all outstanding issues. The appendix is subject to approval by the Workers’ Compensation Court. It MUST accompany the Form CS-337, and be dated and signed by all parties under penalty of perjury. 1. It is hereby agreed by and between the spouse or other person who may be defined as a dependent of the deceased for purposes of workers’ compensation death benefits or the guardian of such person, and the employer/insurance carrier that the above named deceased sustained a compensable accidental injury on or about ________________________________, ___________, while in the employ of the employer, from and as a result of which the deceased died on ________________________________, ___________. The deceased’s average weekly wage before the date of death was $________________. 2. The deceased’s employment was covered by the workers’ compensation laws of the state and the Workers’ Compensation Court has jurisdiction in this matter. 3. The parties agree the proper beneficiaries of the deceased are identified on a duly executed and authenticated proof of loss (Form 20) filed in this case and the claim for benefits asserted by the spouse or dependent of the deceased or guardian of such person is substantiated by appropriate documentation which has been certified. 4. This is an agreement in which the spouse or dependent of the deceased or guardian of such person agrees to accept $_______________________ in full and final settlement of all claims for spousal or dependency benefits, as a result of the decedent’s death sustained as a result of the accident referred to above. This sum is in addition to any previous amount(s) paid to such person, and any amount(s) to any medical provider for authorized, reasonable and necessary medical expenses incurred by the deceased due to the injury. Of said sum, $_________________ shall be paid for ________________________ ___________________; and $__________________shall be paid for___________________________________________. If the dependent(s) is a child or are children under the age of eighteen (18), the guardian ad litem designated herein (name)___________________________________________________, shall comply with all deposit, accounting and other obligations set forth in the workers’ compensation laws of this state. 5. In the event the claim is contested, the sum of $_____________________ shall be deducted from this settlement and paid, pursuant to the workers’ compensation laws of this state, to the attorney representing the spouse or dependent or guardian for such person. 6. The employer/carrier agrees to pay all applicable Court costs, and all taxes and assessments to the Oklahoma Tax Commission, as follows: $140.00 to the Workers’ Compensation Court, taxed as costs in this matter, unless previously paid; the Special Occupational Health and Safety Tax in the sum of $_______________________, representing three-fourths of one percent (0.75%) of the compromise settlement amount; if a Court Approved OWN RISK employer or group self-insurance association, the Workers’ Compensation Administration Fund Tax in the sum of $____________________, representing 2% of the compromise settlement amount, and, if applicable by law, the appropriate Self-Insured Guaranty Fund Tax in the sum of $_______________________, representing 1% of the compromise settlement amount; and, in addition to other amounts, if UNINSURED, a Multiple Injury Trust Fund assessment in the sum of $_______________________, representing 5% of the compromise settlement amount. SPOUSE/DEPENDENT/GUARDIAN NAME — PLEASE PRINT EMPLOYER NAME— PLEASE PRINT SPOUSE/DEPENDENT/GUARDIAN ADDRESS NAME OF EMPLOYER’S CARRIER OR OWN RISK GROUP — PLEASE PRINT SPOUSE/DEPENDENT/GUARDIAN — SIGNATURE DATE ATTORNEY FOR SPOUSE/DEPENDENT/GUARDIAN — PLEASE PRINT OBA # ATTORNEY FOR SPOUSE/DEPENDENT/GUARDIAN— SIGNATURE NAME OF EMPLOYER/CARRIER’S ATTORNEY — PLEASE PRINT OBA# EMPLOYER/CARRIER ATTORNEY—SIGNATURE DATE DATE ORDER APPROVING COMPROMISE SETTLEMENT (FORM CS-337) (Death Claim): The Workers’ Compensation Court, having reviewed the evidence, files and records in this matter and being fully advised in the premises, approves the above Compromise Settlement, including attorney fees and the attached appendix to the Compromise Settlement, if any, which Compromise Settlement and appendix are incorporated herein by reference and made a part hereof. The employer/carrier shall comply with this order within fifteen (15) days from the file-stamped date of the order. In that event, and upon passage of twenty (20) days after the file-stamped date of the order, this cause shall be fully and finally closed and resolved, and the Court divested of further jurisdiction therein, PROVIDED the Compromise Settlement determined all issues and matters in the death claim. DONE this ________ day of _______________________________, ___________. BY ORDER OF THE COURT_________________________________________________________ JUDGE Reporter’s Initials 08/11 A copy hereof was mailed by United States regular mail on this file-stamped date to all attorneys of record and unrepresented parties. American LegalNet, Inc. www.FormsWorkFlow.com