WORKERS’ COMPENSATION COURT 1915 NORTH STILES OKLAHOMA CITY, OK 73105-4918 FORM 2 Send original to Workers’ Compensation Court and 1 copy to Insurance Carrier THIS SPACE FOR COURT USE ONLY EMPLOYER’S FIRST NOTICE OF INJURY Please type or print. Enter all dates in MM/DD/YY format. Full Name of Employee - LAST, FIRST, MIDDLE Employee Email Address Complete Address City State Zip Social Security Number Telephone Number Date of Birth Sex Average Weekly Wage Occupation (job description) Length of Employment Years Months Was employment agreement made in Oklahoma? YES NO NOTE: Mediation is available to address certain workers’ compensation disputes. For information, call (405) 522-8760 or In-State Toll Free (800) 522-8210. Date of accident or last exposure Time of accident or exposure o’clock Last date employee worked Date Employer Notified AM Time workday began PM o’clock Has employee returned to work? YES YES NO PM If yes, on what date NO If yes, on what date Place of Accident or Occurrence OSHA Log Case # City: Injury Resulted from: AM Did the employee die? Single Incident Cumulative Trauma County: State: Occupational Disease Nature of Injury or Illness Does employee participate in a certified workplace medical plan: YES NO If yes, name of CWMP: Describe activities when injury occurred with details of how event occurred. Include object or substance which directly injured the employee. Identify part(s) of body involved in injury or illness Full Name and address of Treating Physician (please be complete) Employer’s Insurance Carrier or Own Risk Group Policy/Self-Insured Number Name Phone Policy Period—from Address City State Name Federal ID# Phone # Address City State to Zip Employer’s Name and Complete Address Type of business (Example: manufacturing, food service, construction) Type of Ownership: Private State Government Zip NAICS Number County Government Local Government Upon filing this Notice of Injury, permission is given to the Administrator of the Workers' Compensation Court, the Insurance Commissioner, the Attorney General, a District Attorney or their designees to examine all records relating to the notice, any matter contained in the notice, and any matter relating to the notice. 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. The undersigned hereby declares under penalty of perjury that they have examined this notice and all statements contained herein are true, correct and complete, to the best of their knowledge. The undersigned certifies this Form 2 was sent to the Workers’ Compensation Court and a copy thereof to the employer’s insurer on the date noted below: Signed By Telephone Number Signature of Preparer Name and Title of Preparer (Please Print) A Form 2 must be filed with the Workers’ Compensation Court and sent to the Employer’s workers’ compensation insurance carrier within 10 days of notice that an employee has suffered an accidental injury which results in lost time beyond the shift, or requires medical attention away from the work site, fatal or otherwise. Form 2s filed with the Workers’ Compensation Court are confidential and not subject to public disclosure except as authorized by law. FILING OF THIS FORM IS NOT AN ADMISSION OF LIABILITY OR THAT THE EMPLOYEE HAS PROVIDED PROPER NOTICE OF INJURY. Area Code and Number Date American LegalNet, Inc. www.FormsWorkFlow.com Rev. 08/11