JOINT PETITION Send original and 6 copies to Workers’ Compensation Court WORKERS’ COMPENSATION COURT THIS SPACE FOR COURT USE ONLY 1915 NORTH STILES OKLAHOMA CITY, OKLAHOMA 73105-4918 Full Name of Injured Employee (Claimant) Claimant’s Social Security Number Name of Employer (Respondent) FILE NO. Employer’s Insurance Carrier, Permit # for Court Approved Individual Self-Insured or Own Risk Group, Uninsured Date of injury (Please type or Print ALL information legibly in ink) The above named parties come now and agree to a compromise of the issues in this case on a joint petition, and state the following facts to wit: 1. The respondent carries a policy of insurance or carries its own risk in compliance with the Workers’ Compensation Act of the State of Oklahoma, covering the period in which the claimant’s accident is alleged to have occurred. 2. The claimant, on or about ____________________, __________ was an employee of the respondent, engaged in employment subject to and covered by the Workers’ Compensation Act, and received a wage entitling the employee to a compensation rate of $_________________ for Permanent Partial Disability. 3. Claimant alleges that on or about said date claimant sustained an accidental personal injury arising out of and in the course of said employment as follows: __ _____________________________________________________________________________________________________________________________ 4. As a result of said injury claimant was temporarily totally disabled from ______________,__________ to ____________________,____________ or a period of ____________ weeks, ______________ days for which claimant received $__________________, from the respondent or insurance carrier. Claimant hereby agrees to accept in settlement of all claims against the respondent and insurance carrier the sum of $__________________________. Claimant agrees that this is in full, final and complete settlement of all claims for statutory medical aid, for rehabilitation procedures, and for compensation, including compensation for temporary disability, permanent disability, the benefits of physical and vocational rehabilitation or loss of wage earning capacity which claimant now has or may hereafter have as a result of any and all injuries sustained in the accident. It is further agreed that said sum is in addition to any sum or sums heretofore paid claimant and in addition to the authorized, reasonable and necessary medical and rehabilitative expenses heretofore incurred by claimant by reason of said accidental personal injury. The sum of $_________________________________ shall be deducted from this award and paid to claimant’s attorney pursuant to 85 O.S., Section 30. WHEREFORE, this joint petition is submitted to the Workers’ Compensation Court for its approval and final order in compliance with the laws of the State of Oklahoma and it is understood that this compromise settlement shall be null and void unless approved by the Workers’ Compensation Court. 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. ___________________________________________________________ _________________________________________________________ Name of Claimant Name of Respondent Signature of Claimant Name of Insurance Carrier or Own Risk Group X______________________________________________ _______________________________________________ Address of Claimant _______________________________________________ Name of Attorney for Claimant OBA # X______________________________________________ ______________________________________________ ______________________________________________ Type or Print Name of Respondent/Insurer Attorney OBA # X_____________________________________________ Signature of Respondent/Insurer Attorney Signature of Attorney for Claimant ORDER APPROVING JOINT PETITION Now on this ______________ day of _______________________ , _______, the Workers’ Compensation Court having reviewed the evidence, the files and records in said cause and being fully advised in the premises, finds that the above Joint Petition, including attorney fees, incorporated herein and made a part hereof by reference, should be and is hereby approved. IT IS THEREFORE ORDERED, that the respondent or insurance carrier pay to claimant the sum of $_________________________, same being for Permanent Disability (______%) to _______________________________________________________; the additional sum of $___________________shall be paid for __________________________________________________________________________. IT IS FURTHER ORDERED, that respondent or insurance carrier shall pay costs in the sum of $140.00 for each case, unless the court cost was previously paid, the Special Occupational Health and Safety Fund Tax in the sum of $_______________, representing three-fourths of one percent of the entire award, excluding medical payments and temporary total disability, and that respondent, if own risk, shall also pay the sum of $_________________, representing 2% of the total compensation paid herein for permanent disability and death benefits to the Workers’ Compensation Administration Fund and the sum of $_______________, representing 1% of said award to the appropriate Self-Insured Guaranty Fund, if applicable by law. IT IS THEREFORE ORDERED, that the respondent, if uninsured, shall pay a Multiple Injury Trust Fund assessment $_______________________, representing 5% of the total compensation paid herein for permanent disability and death benefits. in the sum of IT IS FURTHER ORDERED, that within 20 days from the filing date of this order, respondent or insurance carrier shall comply herewith, whereupon this cause shall be fully and finally closed and adjudicated, and the Court divested of further jurisdiction herein. Reporter’s Initials Rev 11/10 copy hereof was mailed by United States regular mail on this file-stamped date to all attorneys of record and to unrepresented parties. A BY ORDER OF__________________________________________________________________ American LegalNet, Inc. www.FormsWorkFlow.com