Fillable Workers Comp Referral

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Workers Comp Referral

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WORKERS’ COMPENSATION REFERRAL FORM
Name of Medical Facility:
Dear Medical Provider,
Please be advised that this employee is authorized to receive initial care for a reported on-the-job injury and/or
illness at Oral Roberts University. The incident will be investigated. This authorization is not an admission of
liability or compensability under the Oklahoma Workers’ Compensation Act.
Name of Employee:
Authorized by:
Immediate Supervisor or Departmental Manager
Authorizing Signature: Date:
Department:
Phone:
Fax claims to:
Travelers
PO Box 660456
Dallas, TX 75226
1-800-238-6225
1-800-832-7839
Fax: 877-786-5577
If you have any questions, please contact Risk Management at (918)495-7560.
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Workers Comp Referral

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Completed 28 February 2020

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