REQUEST FOR CLAIMS FILE INFORMATION/PRIOR CLAIMS Please complete this form and return it to the following address, together with all appropriate documents and a pre-addressed stamped envelope. This request will NOT be processed if the self-addressed stamped envelope is not provided. Applicable search fees ($1 per search conducted) and copy charges apply. WORKERS' COMPENSATION COURT of EXISTING CLAIMS 1915 N. Stiles Avenue, Suite 127 Oklahoma City, OK 73105-4918 (405) 522-8600 ********************************************************************************************************** Please indicate By Name the TYPE of search you are requesting (please type or print): By Name and the LAST 4 DIGITS of the Social Security Number (Authorization from the holder of the Social Security Number is required.) First Name Last Name First Name Last Name I authorize the use of my Name and the LAST 4 DIGITS of my Social Security Number to search for workers' compensation information as evidenced by my signature below: Signature of SSN Holder: Date Social Security #: LAST 4 DIGITS ONLY XXX-XX-____________________________________ I declare under PENALTY OF PERJURY that the information sought hereby is not for a purpose in violation of any state or federal law. I understand that I am required by law to disclose the person for whom this search request is being made, if different from myself. This search is being made on behalf of the following: Name: _________________________________________________________________ Address : _______________________________________________________________ City: _______________________________ State: _____ Zip Code: ______________ Please indicate your information below (the preparer of this form): Preparer's Signature Preparer's Printed Name: Telephone # Address: City: State: Zip Code: This document is considered a public record under Oklahoma law. Revised 1/13/15 American LegalNet, Inc. www.FormsWorkFlow.com