Send original to Court of Existing Claims and 1 copy to All Other Parties of Record (Please type or print) In re claim of: Full Name of Claimant (Injured Employee) FORM 13 THIS SPACE FOR COURT USE ONLY COURT OF EXISTING CLAIMS 1915 NORTH STILES, STE 127 OKLAHOMA CITY, OKLAHOMA 73105-4918 Claimant's Social Security Number (LAST 4 DIGITS ONLY) XXX-XX-_________________________ Name of Employer or Respondent REQUEST FOR PREHEARING CONFERENCE WCC FILE NO. Date of Injury Employer's Insurance Carrier, Permit # for Court Approved Individual Self-Insured or Own Risk Group, Uninsured NOTE: Mediation is available to address certain workers' compensation disputes. For information, call (918) 581-2714. 1. Movant respectfully requests that the captioned cause be set for Prehearing Conference at the earliest possible date to address the following issue(s): a. Motion to Terminate Temporary Compensation. b. Objection to Termination of Temporary Compensation based on: 85 O.S. Section 332(G) c. Motion to Appoint an Independent Medical Examiner. d. Employer Objection to Claimant's Request for Change of Physician. e. Motion to Consolidate. LIST ALL COURT FILE NUMBERS, EXCLUDING THE ONE LISTED ABOVE. ____________ f ____________ ____________ ____________ Motion to Hold in Abeyance. and INSURER, and the alleged DATE OF INJURY. (Use additional sheets if necessary.) A COPY OF THIS MOTION MUST BE MAILED TO EACH ADDITIONAL PARTY AND INSURER LISTED. Additional Party & Address, including City/State/Zip Insurer & Address, including City/State/Zip Alleged Date of Injury Court Appointed IME Treating Physician Other _______________________________________ (Specify) g. Motion to Join Additional Parties. Include the name and complete address, including the zip code, of EACH additional party ____________________________________ | __________________________________________ | _____________________ ____________________________________ | __________________________________________ | _____________________ h. Mediation Order. (Note: Contact the Counselor Department directly to pursue mediation by mutual agreement without Court order.) i. Motion to Review Permanent Total Disability Status pursuant to 85 O.S., Section 336(C). j. Other __________________________________________________________________________________________ (specify). 2. Has a trial judge previously been assigned by the Court to hear all matters relating to the above-captioned cause of action? YES NO ASSIGNED TRIAL JUDGE: ___________________________________. THE PARTY MAKING THIS REQUEST FOR A PREHEARING CONFERENCE HEREBY CERTIFIES THAT THE PARTIES HAVE DISCUSSED THE ISSUE TO BE PRESENTED TO THE COURT AND CANNOT, IN GOOD FAITH, REACH A RESOLUTION OF THE ISSUE WITHOUT THE COURT'S ASSISTANCE. I declare under penalty of perjury that I have examined all statements contained herein and they are true, correct and complete, to the best of my knowledge and belief. Any person who commits workers' compensation fraud, upon conviction, shall be guilty of a felony. I HEREBY CERTIFY THAT A COPY HAS BEEN SENT TO: Opposing Party/Counsel Address (Number and Street) City State Zip Code Signature of Requesting Party Address City Signed this ____________day of _________________, __________. State Zip Code Telephone Number of Requesting Party Print or type name of Attorney OBA # Rev. 06/24/2015 American LegalNet, Inc. www.FormsWorkFlow.com