FORM 3B Send original and 4 copies to: Court of Existing Claims COURT OF EXISTING CLAIMS 1915 NORTH STILES, STE 127 OKLAHOMA CITY, OK 73105-4918 Please check appropriate box I. Original Filing THIS SPACE FOR COURT USE ONLY Name of Claimant (Injured Employee) Name of Employer II. Amends Previously Filed Form 3B (Must clearly state whether amendment is in addition to, or substitute for, prior information.) EMPLOYEE'S FIRST NOTICE OF OCCUPATIONAL DISEASE AND CLAIM FOR COMPENSATION Court use only WCC FILE NO. NOTE: Mediation is available to address certain workers' compensation disputes. For information, call (918) 581-2714. Phone: Social Security #: EMPLOYEE NAME (Last, First, Middle): ( ) NOTE: A voluntary Mediation Program to address certain workers' compensation disputes is available through the Court of Existing Claims. For information, call (405)City, State & or (800) 522-8210. 522-8760 Zip): Sex: Mailing Address (include Date of Birth: Age: (Please type or print) Occupation: Was your employment agreement in Oklahoma? YES NO Avg. Weekly Wage: Length of Employment months_____________ years_________ Date of last exposure to hazard which caused Date of first distinct manifestation: disease: Nature of Disease (example: Reduced breathing capacity or loss of vision) Place of Injury: City/County/State Body Part(s) Injured: Describe how you were exposed to the disease with details of how event occurred. Include object or substance which directly injured you: Have you filed a claim for Social Security Disability Insurance Benefits? YES Are you eligible for Medicare Benefits or will you become eligible for Medicare Benefits within 30 months of the filing of this Notice of Occupational Disease and Claim for Compensation? YES NO NO Are you a previously impaired person due to a prior workers' compensation injury or obvious and apparent pre-existing disability? _______ If "YES", you may be entitled to benefits for combined disabilities from the Multiple Injury Trust Fund. A claim for benefits for combined disabilities against the Multiple Injury Trust Fund may be commenced by filing a "Form 3F" with the Court of Existing Claims. Employer: Complete Mailing Address: Complete Street Address (if different from above): Employer's FEI # (Federal ID Number): City: City: Telephone: State: State: Zip: Zip: Any person receiving temporary disability benefits from an employer or the employer's insurance carrier shall within seven (7) days report in writing to the employer or insurance carrier any change in a material fact or the amount of income the employee is receiving or any change in the employee's employment status, occurring during the period of receipt of such benefits. Any person who commits workers' compensation fraud, upon conviction, shall be guilty of a felony. Upon filing this Notice of Occupational Disease and Claim For Compensation, permission is given to the Administrator of the Court of Existing Claims, the Insurance Commissioner, the Attorney General, a district attorney or their designees to examine all records relating to the notice. The permission granted to the above named persons authorizes them access to medical records pursuant to 76 O.S., § 19, 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. This form is not intended for use as a medical authorization. Nothing shall be construed to waive, limit or impair any evidentiary privilege recognized by law. I declare under penalty of perjury that I have examined this Notice of Occupational Disease and Claim for Compensation, and all statements contained herein are true, correct and complete, to the best of my knowledge and belief. Signed this _______________ day of ________________________ , ________ Name of claimant's attorney if represented: Type or Print Name of Attorney: Mailing Address: City Telephone #: ( ) State Zip OBA# Rev. 06/24/2015 Signature of Attorney for Claimant Signature of Claimant (must be signed by claimant) American LegalNet, Inc. www.FormsWorkFlow.com