CC-Form-1A
Oklahoma Workers' Compensation Notice and Instruction to Employers and Employees
All employees of this employer who are entitled to benefits of the Administrative Workers' Compensation Act are hereby notified that this employer has
complied with all rules of the Workers' Compensation Commission and that this employer has secured payment of compensation for all employees and their
dependents in accordance with the Act. All employees are further notified this employer will furnish first aid, medical, surgical, hospital, optometric, podiatric,
and nursing services, medicine, crutches and other apparatus as may be reasonably necessary in connection with the injury received by the employee, as well as
payments of compensation to any injured employee or the employee’s dependents as provided in the Act.
Any employee who has suffered a compensable injury covered by the Administrative Workers' Compensation Act is entitled to vocational rehabilitation
services, including retraining and job placement, if, as a result of the injury, the employee is unable to perform work for which the person has previous training
or experience.
The Oklahoma Workers' Compensation Commission
has a Counselor Division to provide information to
injured workers, employers, and other interested
persons.
Mediation is available to help resolve certain workers’
compensation disputes. For information, call the
Counselor Division at 405-522-8760 or In-State Toll
Free 800-522-8210.
Signature of Employer
Insurer Name and Address
Employee's Responsibilities In Case of Work Related Injury
If accidentally injured or affected by cumulative trauma or an occupational disease arising out of and in the course of employment, however slight, the
employee should notify the employer immediately. If this employer is a partnership, notice shall be given to any partner. If this employer is a
corporation, notice shall be given to any agent or officer of the corporation upon whom legal process may be served. Notice shall also be given to the
person in charge of business at the location of operations where the injury occurred. Unless oral or written notice is given to the employer within thirty
(30) days, the claim for compensation may be forever barred.
The employee may file a claim for compensation with the WORKERS’ COMPENSATION COMMISSION for an accidental injury, death,
cumulative trauma or occupational disease or illness occurring ON OR AFTER February 1, 2014. Forms to file a compensation claim should be
furnished by this employer and also are available from the Workers’ Compensation Commission. The forms are posted on the Commission’s website,
www.wcc.ok.gov.
A claim for compensation must be filed with the Commission within the time specified by law, or be forever barred. Based on law effective February
1, 2014, a claim for compensation for any accidental injury or death must be filed with the Commission within one (1) year of the date of injury or
death; a claim for compensation for occupational disease or illness must be filed within two (2) years of the last injurious exposure; and a claim for
compensation for cumulative trauma must be filed within one (1) year of the date of injury. A claim for additional compensation is barred unless filed
within one (1) year of the last payment of disability compensation or two (2) years from the date of injury, whichever is longer.
Claims for compensation for accidental injury, death, cumulative trauma or occupational disease or illness occurring BEFORE February 1,
2014 may be filed with the WORKERS’ COMPENSATION COURT OF EXISTING CLAIMS and are subject to different notice of injury
requirements and claims filing deadlines than those for accidental injury, death, cumulative trauma or occupational disease or illness
occurring on or after February 1, 2014. Failure to comply with applicable notice requirements and deadlines may operate to forever bar the
claim. Contact the Commission’s Counselor Division for additional information.
Employer's Responsibilities
The employer must provide employees with immediate first aid, medical, surgical, hospital, optometric, podiatric, and nursing services, medicine,
crutches and other apparatus as may be reasonably necessary in connection with the injury received by the employee. This applies to care for all
injuries and illnesses arising out of and in the course of employment, regardless of their character. Within ten (10) days after the date of receipt of
notice or knowledge of death or injury that results in more than three days’ absence from work for the injured employee, the employer MUST send a
report thereof to the Workers’ Compensation Commission on a CC-Form 2, and also send a copy of the CC-Form 2 to the employer’s insurance
carrier, if any, within the ten-day period.
No agreement by any employee to pay any portion of the premium paid by the employer to a carrier or a benefit fund or department maintained by the
employer for the purpose of providing compensation or medical services and supplies as required by the workers’ compensation laws, shall be valid.
Any employer who makes a deduction for such purposes from the pay of any employee entitled to benefits under the workers’ compensation laws shall
be guilty of a misdemeanor.
No agreement by any employee to waive workers' compensation rights and benefits shall be valid.
Any person who commits workers' compensation fraud, upon conviction, shall be guilty of a felony
punishable by imprisonment, a fine or both.
Workers' Compensation Commission
1915 North Stiles Avenue
Oklahoma City, Oklahoma 73105-4918
Tele. 405-522-3222 (OKC) · 918 -581-2714 (TU) · In-State Toll Free 800-522-8210
This notice must be posted and maintained by the employer in one or more conspicuous places on the work premises.
Created 2-1-14
Date of Expiration of Insurance Policy (Not applicable to employers
authorized to self-insure.)
