WORKERS’ COMPENSATION COMMISSION THIS SPACE FOR COMMISSION USE ONLY
CC-FORM-2 1915 NORTH STILES AVENUE STE 231
Applicable to Injuries /Deaths Occurring On or After 2/1/14 OKLAHOMA CITY, OK 73105
Send original to Workers’ Compensation Commission and
1 copy to Insurance Carrier
EMPLOYER’S FIRST NOTICE OF INJURY
Please type or print. Enter all dates in MM/DD/YY format.
Full Name of Employee - LAST, FIRST, MIDDLE Employee Email Address
Complete Address City State Zip
Telephone Number
Employee’s Social Security Number (LAST 4 DIGITS ONLY)
XXX-XX-________________________
Date of Birth Sex Length Date ofofHire:__________________________________Employment: Years Months _______
YES
Average Weekly Wage Occupation (job description) Was employment agreementNO made in Oklahoma?
NOTE: Mediation is available to help resolve certain workers’ compensation disputes. For information, call (405) 522-5308 or In-State Toll Free (855) 291-3612.
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 toIfwork?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)
Address Name Employer’s Insurance Carrier or Own Risk Group Phone City PolicyPolicy/Self-InsuredPeriod: From Number State To Zip
AddressName Employer’s Name and Complete Address Federal ID# City Phone # State Zip
Type of business (Example: manufacturing, food service, construction) NAICS Number
Type of Ownership: Private State Government County Government Local Government
Administrative Workers’ Compensation Act, 85A O.S., §6(A)(1)(a): “Any person or entity who makes any material false statement or
representation, who willfully and knowingly omits or conceals any material information, or who employs any device, scheme, or artifice,
or who aids and abets any person for the purpose of: (1) obtaining any benefit or payment … shall be guilty of a felony.”
Any person who commits workers’ compensation fraud, upon conviction, shall be guilty of a felony punishable by imprisonment, a fine
or both.
The undersigned hereby declares under PENALTY OF PERJURY that they have
examined this notice and all statements contained herein are true, correct
and complete, to the best of their knowledge. The undersigned certifies this
CC-Form 2 was sent to the Workers’ Compensation Commission and a copy A CC-Form 2 must be sent to the Workers’ Compensation
thereof to the employer’s insurer on the date noted below: Commission and to the employer’s workers’ compensation
insurance carrier within 10 days after the date of receipt of
notice or knowledge of death or injury that results in more
Signed Signature of Preparer than three days’ absence from work for the injured employee.
PROVIDING THIS FORM TO THE COMMISSION IS NOT
By Name and Title of Preparer (Please Print) EVIDENCE OF ANY FACT STATED IN THE REPORT IN ANY
PROCEEDING WITH RESPECT TO THE INJURY OR DEATH ON
ACCOUNT OF WHICH THE REPORT IS MADE.
Telephone Number Area Code and Number
Date
Revised 2-2-16