FORM 3F THIS SPACE FOR COURT USE ONLY WORKERS’ COMPENSATION COURT 1915 NORTH STILES OKLAHOMA CITY, OK 73105-4918 Send original to Workers’ Compensation Court and 1 copy to Multiple Injury Trust Fund Please check appropriate box I. Original Filing II. Amends Previously Filed Form 3F (Must clearly state whether amendment is in addition to, or substitute for, prior information.) Name of Claimant (injured employee) EMPLOYEE’S CLAIM FOR BENEFITS FROM THE MULTIPLE INJURY TRUST FUND MULTIPLE INJURY TRUST FUND P.O. Box 528801 Oklahoma City, OK 73152 FILE NO. (Please type or print) EMPLOYEE NAME (Last, First, Middle) Date of Birth: Mailing Address (include City, State, & Zip) Date of Injury Court File Number for most recent injury Date of Order ) Age: Sex: Percentage of Disability Awarded and Body Part Rate of Weekly compensation for permanent partial disability at the time of the most recent injury Amount of Joint Petition or Other Settlement Court File No. Phone: ( Social Security # Date of Order Date of Injury % of Disability & Body Part P R I O R Amount of JP or Other Settlement Are weekly benefits still being paid on any of the above orders? ______________YES _______________NO If so, when are benefits expected to terminate? List and describe fully any other pre-existing disability for which no award has been made. (Pre-existing disability means any obvious and apparent disability resulting from any cause, which disability is obvious and apparent from observation of a person who is not skilled in the medical profession.) 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. I hereby certify that a true and correct copy of this claim was mailed to the MULTIPLE INJURY TRUST FUND on the _________________ day of ____________________, _______ Name of claimant’s attorney if represented: Type or Print Name of Attorney: OBA # Mailing Address: City: State: Upon filing this Claim For Benefits from the Multiple Injury Trust Fund, permission is given to the Administrator of the Workers’ Compensation Court, the Insurance Commissioner, the Attorney General, a district attorney of their designees to examine all records relating to the claim. The permission granted to the above named individuals or their designees authorizes them to access 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. Zip: Telephone #: ( ) ____________________________________________________________ 2/06 Signature of Attorney for Claimant Signed this __________day of______________________,______________ ____________________________________________________________ Signature of Claimant (must be signed by claimant) American LegalNet, Inc. www.USCourtForms.com