Agreement Between Employer And Employee As To Fact With Relation To An Injury And Payment Of Compensation printable pdf download

THIS SPACE FOR COURT USE ONLY

FORM 14

COURT OF EXISTING CLAIMS

1915 NORTH STILES

Send Original and 5 copies to

OKLAHOMA CITY, OK 73105-4918

Court of Existing Claims

Full Name of Claimant (Injured Employee)

Claimant’s Social Security Number

AGREEMENT BETWEEN EMPLOYER AND EMPLOYEE AS TO FACT

Name of Employer or Respondent

WITH RELATION TO AN INJURY AND PAYMENT OF COMPENSATION

FILE NO.

Employer’s Insurance Carrier, Permit # for Court Approved Individual Self-

Insured or Own Risk Group, Uninsured

Date of Accident

(Please type or Print ALL information legibly in ink)

We, the above named parties, have reached an agreement in regard to

the facts with relation to an injury sustained by said employee and payment of compensation therefor, and submit the following:

1. That said injury was sustained on __________________________, ______, at (time) _________; that claimant’s injury arose out of and in the course of

employment with said employer; that claimant timely notified employer; that claimant’s employment was covered by the Workers’ Compensation Act and that

this court has jurisdiction in the matter.

2. That the nature of said injury was __________________________________, resulting in claimant's Temporary

Total

Disability from

__________________, ______ to __________________, ______ or for a period of ___________ weeks, for which claimant received $________________

in compensation, computed at ______________ per week, based upon claimant’s hourly wage of ___________.

3. That as a result of said injury, claimant sustained Permanent Disability (______%) to ___________________________________, for which claimant is

entitled to $_____________________ per week for ___________ weeks, beginning on __________________ and that employer has furnished all

reasonable and necessary medical services in the treatment of said injury.

4. The sum of $____________________ shall be deducted from this award and paid to the claimant’s attorney as a fair and reasonable fee. Claimant

ACCEPTS the fee amount and payment method, and WAIVES THE RIGHT TO A FEE HEARING.

Claimant REJECTS the fee

Claimant’s Initials

amount and payment method and REQUESTS A FEE HEARING.

Claimant’s Initials

The foregoing agreement is herewith submitted for the order, decision or award of this court, under the provisions of the Workers’ Compensation Act

of the State of Oklahoma. It is a condition, however, of this agreement that in the event a change in condition occurs or arises, that the same shall

not be final, but may be reopened and reviewed as provided by law. We, the undersigned, declare under penalty of perjury that we have examined

this agreement and all statements contained herein, and to the best of our knowledge and belief, they are true, correct and complete. Any person who

commits worker’s compensation fraud, upon conviction, shall be guilty of a felony.

Signed this _________ day of ________________________, _________.

___________________________________________________________

Signature of Claimant

Employer or Respondent

___________________________________________________________

Name of Insurance Carrier or Own Risk Group

Address of Claimant

___________________________________________________________

Name of Attorney for Claimant

OBA #

Type or Print Name of Attorney for Respondent/Insurer

OBA #

___________________________________________________________

Signature of Attorney for Claimant

Signature of Attorney for Respondent/Insurer

Mail Approved Copy To

Order Approving Form 14 Agreement

Now on this ________________ day of ___________________, __________, the Court of Existing Claims having reviewed the evidence submitted herein by

all parties, and being well and fully advised in the premises, finds that the above Form 14 Agreement incorporated herein and made a part hereof by reference

should be and is hereby approved.

IT IS THEREFORE ORDERED, that the respondent or insurance carrier pay to the claimant the sum of $________________, same being for Permanent

Disability (____________%) to ______________________________________________________; to pay authorized, reasonable and necessary medical

expenses incurred by claimant by reason of said injury of ______________, _____________ and within 20 days of this Order, respondent or insurance carrier

shall comply herewith.

IT IS THEREFORE ORDERED, that the respondent, if uninsured, shall pay a Multiple Injury Trust Fund assessment in the sum of $__________________,

representing 5% of the total compensation paid herein for permanent disability and death benefits.

IT IS FURTHER ORDERED, that respondent or insurance carrier shall pay court costs in the amount of $140.00 for each case, unless the court cost was

previously paid, the Special Occupational Health and Safety Tax in the sum of $_________________, representing three-fourths of one percent of the entire

award, excluding medical payments and Temporary Total Disability; and the respondent, if own risk, shall also pay the sum of $_____________ representing 2%

of the total compensation paid herein for Permanent Disability and Death Benefits to the Worker’s Compensation Administration Fund and the sum of

$_____________ representing 1% of said award to the appropriate Self-Insured Guaranty Fund, if applicable by law.

A copy hereof was mailed by United Stated regular mail on this file-

C. 02/01/2014

BY ORDER OF ___________________________________________

stamped date to all attorneys of record and to unrepresented parties.