FORM 3F Send original to Court of Existing Claims and 1 copy to Multiple Injury Trust Fund COURT OF EXISTING CLAIMS 1915 NORTH STILES, STE 127 OKLAHOMA CITY, OK 73105-4918 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.) THIS SPACE FOR COURT USE ONLY Name of Claimant (injured employee) MULTIPLE INJURY TRUST FUND P.O. Box 528801 Oklahoma City, OK 73152 (Please type or print) EMPLOYEE NAME (Last, First, Middle) Mailing Address (include City, State, & Zip) Court File Number for most recent injury Amount of Compromise Settlement or Other Settlement Date of Injury EMPLOYEE'S NOTICE OF CLAIM FOR BENEFITS FROM THE MULTIPLE INJURY TRUST FUND WCC FILE NO. Social Security # (LAST 4 DIGITS ONLY) XXX-XX-________________ Phone: ( ) Age: Sex: Date of Birth: Date of Order Percentage of Disability Awarded and Body Part Rate of weekly compensation for permanent partial disability/permanent partial impairment at the time of the most recent injury Court File No. Date of Injury Date of Order % of Disability & Body Part P R I O R Are weekly benefits still being paid on any of the above orders? YES Amount of Compromise Settlement or Other Settlement 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.) Any person who commits workers' compensation fraud, upon conviction, shall be guilty of a felony. Name of claimant's attorney if represented: Type or Print Name of Attorney: Mailing Address: City: Telephone #: ( ) State: Zip: OBA # Upon filing this Employee's Notice of Claim for Benefits from the Multiple Injury Trust Fund, 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 claim, any matter contained in the claim, and any matter relating to the claim. 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. I declare under penalty of perjury that I have examined this Notice of Claim for Benefits from the Multiple Injury Trust Fund and all statements contained herein are true, correct and complete, to the best of my knowledge. I certify a true and correct copy of this Notice of Claim was mailed to the MULTIPLE INJURY TRUST FUND on the date noted below. Signed this __________day of______________________,_______________ ____________________________________________________________ Signature of Attorney for Claimant Rev. 06/24/2015 ________________________________________________________________ Signature of Claimant (must be signed by claimant) American LegalNet, Inc. www.FormsWorkFlow.com