CC-FORM-2
Applicable to Injuries /Deaths Occurring On or Aer 2/1/14
Send original to Workers’ Compensaon Commission and
1 copy to Insurance Carrier
Please type or print. Enter all dates in MM/DD/YY format.
WORKERS’ COMPENSATION COMMISSION
1915 NORTH STILES AVENUE STE 231
OKLAHOMA CITY, OK 73105
EMPLOYER’S FIRST NOTICE OF INJURY
THIS SPACE FOR COMMISSION USE ONLY
Employee’s Social Security Number (LAST 4 DIGITS ONLY)
XXX-XX-________________________
Average Weekly Wage
Telephone Number
Occupaon (job descripon)
Sex
Full Name of Employee - LAST, FIRST, MIDDLE
Complete Address City State Zip
Date of Birth
Was employment agreement made in Oklahoma?
YES NO
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 of accident or last exposure
Length of Employment: Years Months _______
Date of Hire:__________________________________
Time of accident or exposure
o’clock AM PM
Date Employer Noed Time workday began
o’clock AM PM
Last date employee worked Has employee returned to work?
YES NO If yes, on what date ? __________________________
Did the employee die?
YES NO If yes, on what date ?__________________________________________
Place of Accident or Occurrence
City: County: State:
Injury Resulted from: Single Incident Cumulave Trauma Occupaonal Disease
Nature of Injury or Illness
Describe acvies when injury occurred with details of how event occurred. Include object or substance which directly injured the employee.
Idenfy part(s) of body involved in injury or illness
Full Name and address of Treang Physician (please be complete)
Employer’s Insurance Carrier or Own Risk Group Policy/Self-Insured Number
Name Phone Policy Period: From To
Address City State Zip
Type of business (Example: manufacturing, food service, construcon) NAICS Number
Employer’s Name and Complete Address
Name Federal ID# Phone #
Address City State Zip
Type of Ownership: Private State Government County Government Local Government
Administrave Workers’ Compensaon Act, 85A O.S., §6(A)(1)(a): “Any person or enty who makes any material false statement or
representaon, who willfully and knowingly omits or conceals any material informaon, or who employs any device, scheme, or arce,
or who aids and abets any person for the purpose of: (1) obtaining any benet or payment … shall be guilty of a felony.”
Any person who commits workers’ compensaon fraud, upon convicon, shall be guilty of a felony punishable by imprisonment, a ne
or both.
Signed
Signature of Preparer
By
Name and Title of Preparer (Please Print)
Telephone Number
Area Code and Number
Date
The undersigned hereby declares under PENALTY OF PERJURY that they have
examined this noce and all statements contained herein are true, correct
and complete, to the best of their knowledge. The undersigned ceres this
CC-Form 2 was sent to the Workers’ Compensaon Commission and a copy
thereof to the employer’s insurer on the date noted below:
A CC-Form 2 must be sent to the Workers’ Compensaon
Commission and to the employer’s workers’ compensaon
insurance carrier within 10 days aer the date of receipt of
noce or knowledge of death or injury that results in more
than three days’ absence from work for the injured employee.
PROVIDING THIS FORM TO THE COMMISSION IS NOT
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.
Does employee parcipate in a cered workplace medical plan: YES NO
If yes, name of CWMP:
OSHA Log Case #
Employee Email Address
Revised 2-2-16
1901 N Walnut Avenue Oklahoma City Oklahoma 73105
Oklahoma Baptist University
500 West University, Box 61207 Shawnee Oklahoma 74804
Mike Johnson, Director of Human Resources
