Send original to Court of Existing Claims and 1 copy to All Other Parties of Record FORM 20 COURT OF EXISTING CLAIMS 1915 NORTH STILES OKLAHOMA CITY, OKLAHOMA 73105-4918 (PLEASE TYPE OR PRINT) THIS SPACE FOR COURT USE ONLY IN THE MATTER OF THE DEATH OF Full Name of Deceased Employee Full Name of Person Filing Proof of Loss PROOF OF LOSS (DEATH CLAIM) (Lump Sum Benefits) WCC FILE NO. Deceased Employee's Social Security Number (LAST 4 DIGITS ONLY) Name of Employer Employer's Insurance Carrier, Permit # for Court Approved Individual Self-Insured or Own Risk Group, Uninsured XXX-XX-_____________________ STATE OF OKLAHOMA ) ) COUNTY OF __________________________) SS. (PLEASE TYPE OR PRINT) __________________________________________________, (name of person filing proof of loss) of lawful age, being first duly sworn on oath, alleges and states: The affiant is the ______________________________________________, (relation to deceased employee) of the deceased employee. The above named deceased sustained a compensable accidental injury on or about _____________________________, ___________ while in the employ of the employer, from and as a result of which the deceased died on ______________________________________, ____________. At the time of death, the deceased was lawfully married to _______________________________________________________________ (name of spouse) whose address is ____________________________________________________________________ and left surviving the following named children and dependents: CHILDREN (List additional children on the back of this form.) FULL NAME 1. _______________________________________________________ 2. _______________________________________________________ 3. _______________________________________________________ 4. _______________________________________________________ DATE OF BIRTH _________________ _________________ _________________ _________________ ADDRESS _____________________________________________ _____________________________________________ _____________________________________________ _____________________________________________ DEPENDENTS (Parents, brothers, sisters, grandparents and grandchildren, as defined by and if ACTUALLY DEPENDENT under the workers' compensation laws of Oklahoma. List additional actual dependents on the back of this form. Clearly identify them as "Dependents.") FULL NAME 1. _______________________________________________________ 2. _______________________________________________________ 3. _______________________________________________________ 4. _______________________________________________________ DATE OF BIRTH _________________ _________________ _________________ _________________ ADDRESS _____________________________________________ _____________________________________________ _____________________________________________ _____________________________________________ I affirm I have read this Proof of Loss and declare under penalty of perjury that all statements are true and accurate to the best of my knowledge and belief. I certify that on ___________________________________, ________ I mailed a copy of necessary marriage, birth and death certificates to the opposing party/counsel as noted below. NOTE: A certified copy of each of these documents, and other documents necessary to establish actual dependency as defined by law, must be offered at the time of trial or settlement. ______________________________________________________________________ Signature of Person Completing this Proof of Loss DATE I HEREBY CERTIFY THAT A COPY HAS BEEN SENT TO: Any person who commits workers' compensation fraud, upon conviction, shall be guilty of a felony. Opposing Party Address (Number and Street) City State Zip Code Name of claimant's attorney, if represented Address of Attorney (include City, State and Zip Code) Telephone # Signature of Claimant's Attorney OBA # DATE C. 02/01/2014 American LegalNet, Inc. www.FormsWorkFlow.com