1915 NORTH STILES STE 231 OKLAHOMA CITY, OK 73105-4918 Full Name of Deceased Employee Full Name of Spouse or Dependent or Guardian of Such Person XXX-X Name of Employer -Insured or Own Risk Group, Uninsured WCC File Number Date of Death This agreement is prepared and submitted pursuant to Section 47 of the Administrative 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, Commission, 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 WCommission. It MUST accompany the Death Claim Settlement Order and be dated and signed by all parties under penalty of perjury.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 death benefits or the guardian of such person, and the employer/insurance carrier that the above named deceased sustained a compensable accidentalinjury on or about , , while in the employ of the employer, from and as a result of which the deceased. has jurisdiction inthis matter.The parties agree the proper beneficiaries of the deceased are identified on a duly executed and authenticated proof of loss (CC-Form-20) filed in this caseand the claim for benefits asserted by the spouse or dependent of the deceased or guardian of such person is substantiated by appropriate documentationwhich has been certified.This is an agreement in which the spouse or dependent of the deceased or guardian of such person agrees to accept $ in fullult of the accident referred toabove. 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 andnecessary 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 orare children under the age of eighteen (18), the guardian ad litem designated herein (name),In the event the claim is contested, the sum of $ shall be deducted from this settlement and paid, pursuant compensation laws of this state, to the attorney representing the spouse or dependent or guardian for such person.The employer/carrier agrees to pay all applicable Commission costs, and all taxes and assessments to the Oklahoma Tax Commission, as follows: $140.00th and Safety Tax in the sumof $, representing three-fourths of one percent (0.75%) of the settlement amount; if a Commission Approved OWN RISKemployer or group self-resenting 2% of thesettlement amount; and, in addition to other amounts, if UNINSURED, a Multiple Injury Trust Fund assessment in the sum of $,representing 5% of the settlement amount. ORDER APPROVING DEATH CLAIM SETTLEMENT ORDER: records in this matter and being fully advised in the premises, approves the above Death Claim Settlement Order, including attorney fees and the attached appendix to the Death Claim Settlement Order, if any, which Death Claim Settlement Order 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 if the Death Claim Settlement Order determined all issues and matters in the claim, this cause shall be fully and finally closed and resolved, and the Commission divested of further jurisdiction therein. DONE this day of , . BY ORDER OF ADMINISTRATIVE LAW JUDGE IN RE DEATH OF: (Please type or Print ALL information legibly in ink.) THIS SPACE FOR COMMISSOIN USE ONLY SPOUSE/DEPENDENT/GUARDIAN NAME PLEASE PRINT SPOUSE/DEPENDENT/GUARDIAN ADDRESS SPOUSE/DEPENDENT/GUARDIAN SIGNATURE DATE ATTORNEY FOR SPOUSE/DEPENDENT/GUARDIAN PLEASE PRINT OBA # EMPLOYER NAME PLEASE PRINT EMPLOYER/CARRIER ATTORNEYSIGNATURE DATE PLEASE PRINT OBA# PLEASE PRINT ATTORNEY FOR SPOUSE/DEPENDENT/GUARDIAN SIGNATURE DATE DEATH CLAIM SETTLEMENT ORDER A copy hereof was mailed by United States regular mail on this file-stamped date to all attorneys of record and unrepresented parties. compensation fraud, upon conviction, shall be guilty of a felony, punishable by imprisonment, a fine or both.. representation, who willfully and knowingly omits or conceals any material information, or who employs any device, scheme, or artifice, or who aids and abets any person for the purpose of: American LegalNet, Inc. www.FormsWorkFlow.com