COURT OF EXISTING CLAIMS THIS SPACE FOR COURT USE ONLY
FORM 2 1915 NORTH STILES, STE 127
Send original to
Court of Existing Claims and 1 copy to OKLAHOMA CITY, OK 73105-4918
Insurance Carrier
Please type or print. Enter all dates in MM/DD/YY format. EMPLOYER’S FIRST NOTICE OF INJURY
Full Name of Employee - LAST, FIRST, MIDDLE Employee Email Address
Complete Address City State Zip
Telephone Number Social Security Number
Date of Birth Sex Length Years of Employment Months
YES
Average Weekly Wage Occupation (job description) Was employment agreementNO made in Oklahoma?
NOTE: Mediation is available to address certain workers’ compensation disputes.
For information, call (918) 581-2714.
Date Employer Notified Time workday began
Date of accident or last exposure Time of accident or exposureo’clock AM PM o’clock AM PM
Did the employee die?
Last date employee worked Has employee NO returned to work?If yes, on what date YES NO If yes, on what date
YES
OSHA Log Case #
Place City: of Accident or Occurrence County: State:
Injury Resulted from: Single Incident
Cumulative Trauma Occupational Disease
Nature of Injury or Illness Does employee participate in a certified workplace medical plan: YES NO
If yes, name of CWMP:
Describe activities when injury occurred with details of how event occurred. Include object or substance which directly injured the employee.
Identify part(s) of body involved in injury or illness
Full Name and address of Treating Physician (please be complete)
AddressName Employer’s Insurance Carrier or Own Risk Group PhoneCity StatePolicyPolicy/Self-InsuredPeriod—from Number Zip to
AddressName Employer’s Name and Complete Address FederalCity ID# StatePhone # Zip
Type of business (Example: manufacturing, food service, construction) NAICS Number
Type of Ownership: Private State Government County Government Local Government
Upon filing this Notice of Injury, permission is given to the Administrator of the Court of Existing Claims, the Insurance Commissioner, the Attorney
General, a District Attorney or their designees to examine all records relating to the notice, any matter contained in the notice, and any matter relating
to the notice.
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.
Any person who commits workers’ compensation fraud, upon conviction, shall be guilty of a felony.
The undersigned hereby declares under penalty of perjury that they have
examined this notice and all statements contained herein are true, correct and A Form 2 must be filed with the Court of Existing Claims and sent to
complete, to the best of their knowledge. The undersigned certifies this Form 2 the Employer’s workers’ compensation insurance carrier within 10
was sent to the Court of Existing Claims and a copy thereof to the employer’s days of notice that an employee has suffered an accidental injury
insurer on the date noted below: which results in lost time beyond the shift, or requires medical
attention away from the work site, fatal or otherwise. Form 2s filed
with the Court of Existing Claims are confidential and not subject to
Signed public disclosure except as authorized by law.
Signature of Preparer
By FILING OF THIS FORM IS NOT AN ADMISSION OF LIABILITY OR
Name and Title of Preparer (Please Print) THAT THE EMPLOYEE HAS PROVIDED PROPER NOTICE OF
INJURY.
Telephone Number
Area Code and Number
Date
Rev. 06/24/2015