Form 1A Oklahoma Workers' Compensation Notice and Instruction to Employers and Employees All employees of this employer who are entitled to benefits of the Workers' Compensation Code are hereby notified that this employer has complied with all rules of the Workers' Compensation Court and that this employer has secured payment of compensation for all employees and their dependents in accordance with the Code. All employees are further notified this employer will furnish first aid, medical, diagnostic, surgical and any other like services required by law as well as payments of compensation to any injured employee as provided in the Workers’ Compensation Code. Any employee who has suffered a compensable injury covered by the Workers' Compensation Code shall be entitled to vocational rehabilitation services, including retraining and job placement, if, as a result of the injury, the employee is unable to perform the same occupational duties the employee was performing prior to the injury. The Oklahoma Workers' Compensation Court has a counselor (ombudsman) program to provide information to injured workers, employers, and other interested parties. Signature of Employer Mediation is available to address certain workers’ compensation disputes. Insurer & Insurer Phone Number For information, call 405-522-8760 or In-State Toll Free 800-522-8210. Employee's Responsibilities In Case of Work Related Injury If accidentally injured or affected by cumulative trauma or an occupational disease arising out of and in the course of employment, however slight, the employee should notify the employer immediately. If this employer is a partnership, notice shall be given to any partner. If this employer is a corporation, notice shall be given to any agent or officer of the corporation upon whom legal process may be served. Notice shall also be given to the person in charge of business at the location of operations where the injury occurred. Unless notice is given to the employer or medical treatment is rendered within thirty (30) days of injury, any claim for compensation may be forever barred. If accidentally injured or affected by cumulative trauma or an occupational disease, the employee may file a claim for compensation with the Workers' Compensation Court. Forms to file a compensation claim should be furnished by this employer and also are available from the Workers’ Compensation Court. The forms are posted on the Court’s web site, www.owcc.state.ok.us/court_forms.htm. A claim for compensation must be filed with the Court within the time specified by law, or be forever barred. Based on law effective August 26, 2011, a claim for compensation for any accidental injury or death must be filed with the Court within two (2) years from the date of the accidental injury or death; a claim for compensation for occupational disease must be filed within two (2) years of either the last hazardous exposure or from the date the disease first became manifest, which ever last occurred; and a claim for compensation for cumulative trauma must be filed within two (2) years of when the employee was last employed by the employer. Provided, claims may be filed within two (2) years from the date of the last medical treatment authorized by the employer or payment of any compensation or remuneration paid in lieu of compensation. 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. Employer's Responsibilities The employer must provide employees with immediate first aid, medical, diagnostic, surgical and any other like services that are reasonable and necessary. This applies to care for all injuries and illnesses arising out of and in the course of employment, regardless of their character. If an employee is injured and this results in the loss of time beyond his/her shift, or requires medical attention away from the work site (fatal or otherwise), the employer MUST file a Form 2 with the Workers’ Compensation Court within ten (10) days of the notice of injury. The employer must provide a copy of the Form 2 to the employer's workers' compensation insurance carrier, if any. No agreement by any employee to pay any portion of premiums paid by the employer to maintain or carry compensation insurance as required by law shall be valid. Any employer who deducts money from the wages or salary of any employee for that purpose who is entitled to workers' compensation shall be guilty of a misdemeanor. If the employer has actual notice of an undisputed injury and the employer's insurance carrier fails to commence weekly temporary total disability benefit payments due within the time provided by law, the insurer shall pay to the employee a penalty of fifteen percent (15%) of the unpaid or delayed weekly benefits. No agreement by any employee to waive workers' compensation rights and benefits shall be valid. Any person who commits workers' compensation fraud, upon conviction, shall be guilty of a felony. Workers' Compensation Court 1915 North Stiles Avenue Oklahoma City, Oklahoma 73105-4918 Tele. 405- 522-8600 (OKC) · 918 -581-2714 (TU) · In-State Toll Free 800-522-8210 Web Site · www.owcc.state.ok.us 08/11 This notice must be posted and maintained by the employer in one or more conspicuous places. American LegalNet, Inc. www.FormsWorkFlow.com