1915 NORTH STILES AVENUE STE 231 OKLAHOMA CITY, OK 73105 XXX-X Name of Employer -Insured or Own Risk Group, Uninsured Commission File Number Date of Injury JOINT PETITION SETTLEMENTStatutes. By signing below, each party affirms that they have read and understand its provisions, declares under penalty of perjury that all statements are true and accurate ssion, is conclusive, final and binding on all the parties involved. BY THIS AGREEMENT, the parties settle upon and determine (check one): ALL ISSUES AND MATTERS IN THE CLAIM SOME, BUT NOT ALL, ISSUES AND MATTERS IN THE CLAIM Attach appendix (Settlement and Resolution of Claim With Full Release) of all outstanding issues. The appendix is subject to approval by Compensation Commission. It MUST accompany the CC-JOINT PETITION, and be dated and signed by all parties under penalty of perjury. 1.It is hereby agreed by and between the above named parties that the claimant alleges to have sustained a compensable accidental injury or occupationaldisease or illness on or about , , while in the employ of the employer, causing the following injury (describenature of injury,and resulting in temporary total disability from , to, or for a period of weeks, days, for which the claimant received $in to a compensation rate of$ for Temporary Total Disability and $ for Permanent Partial Disability.2.A claim for compensation was filed by the claimant for the injury, or, if the claimant is not represented by an attorney, an Emp-Form- 3.This is an agreement in which the claimant agrees to accept $ in full and final settlement of all claims for: (describe injury) sustained asa result of the accident referred to above, including any claim by the claimant for past, present and future compensation for temporary total disability, temporarypartial disability, permanent partial disability or permanent total disability, statutory medical treatment, physical and vocational rehabilitation benefits, or loss ofwage earning capacity, as a result of any and all injuries sustained in the accident. This sum is in addition to any previous amount(s) paid to the claimant, andany amount(s) for authorized, reasonable and necessary medical and rehabilitative expenses previously incurred by the claimant due to the injury. Of said sum,$ shall be paid for permanent partial disability(%) to and $ shall be paid for . For Social Security offset purposes, and if applicable, the claimant agrees to accept and the employer/carrier agrees to pay a lump sum ofman) shall be considered to be$ a month for months, beginning , .worthe state.The employer/carrier agrees to pay all applicable Commission costs, and all taxes and assessments to the Oklahoma Tax Commission, as follows: $140.00 toand Safety Tax in the sum of$, representing three-fourths of one percent (0.75%) of the joint petition settlement amount, excluding medical payments and temporarytotal disability compensation; if a Commission Approved OWN RISK employer or group self-assessment in the sum of $, representing 2% of the joint petition settlement amount; and, in addition to other amounts, ifUNINSURED, a Multiple Injury Trust Fund assessment in the sum of $, representing 5% of the joint petition settlement amount. t or representation, who willfully and knowingly omits or conceals any material information, or who employs any device, scheme, or artifice, or who aids and abets any person for the purpose of: (1) obtaining any ORDER APPROVING JOINT PETITION SETTLEMENT: being fully advised in the premises, approves the above Joint Petition Settlement, including attorney fees, if any, and the attached appendix to the Joint Petition Settlement, if any, which Joint Petition Settlement and appendix are incorporated herein by reference and made a part hereof. If a child support lien wercarrier shall include the name of the person or government agency asserting the lien on any check for temporary total disability, permanent partial disability or permanent total disability. The employer/carrier shall comply with this order within twenty (20) days from the file stamped date of the order. In that event, and if the Joint Petition Settlement determined all issues and matters in the claim, this cause shall be fully and finally closed and resolved, and the Commission divested of further jurisdiction therein. DONE this day of , . BY ORDER OF In re Claim of: (Please type or Print ALL information legibly in ink.) THIS SPACE FOR COMMISSION USE ONLY CLAIMANT NAME PLEASE PRINT CLAIMANT ADDRESS CLAIMANTSIGNATURE DATE NAME OF CLAIMANT ATTORNEY, if any PLEASE PRINT OBA # EMPLOYER NAME PLEASE PRINT EMPLOYER/CARRIER ATTORNEY SIGNATURE DATE PLEASE PRINT OBA# PLEASE PRINT CLAIMANT ATTORNEY SIGNATURE DATE CC-JOINT PETITION A copy hereof was mailed by United States regular mail on this file-stamped date to all attorneys of record and unrepresented parties. ADMINISTRATIVE LAW JUDGE compensation fraud, upon conviction, shall be guilty of a felony, punishable by imprisonment, a fine or both. American LegalNet, Inc. www.FormsWorkFlow.com