Free Request for Claims file information or prior claims.pub - Oklahoma

Please return this form to the address listed below along with all appropriate documents and a self addressed stamped envelope:

Oklahoma Workers' Compensation Court 1915 N. Stiles Ave. Attn: Records Department Oklahoma City, OK 73105

----------------------------------------------------------------------------Fold along dotted line. Place in a window envelope so that the address appear.

Re Workers' Compensation Claim of: Claimant's Name Last:_____________________________ First:_____________________________

REQUEST FOR CLAIMS FILE INFORMATION/PRIOR CLAIMS

By name or By Social Security # (Requires authorization from holder of Social Security Number)
I authorize the use of my social security number to search for workers' compensation claim information:

Signature of SS# holder:_____________________________________ Date: ___/_____/____ Social Security #: _____--____--_______
I declare under PENALTY OF PURJURY that the information sought hereby is not for a purpose in violation of any state or federal law. I understand that I am required by law to disclose the person for whom this search request is being made, if different from myself.

This search is being made for: Name:____________________________________________________ Address: __________________________________________________ City:________________________ State:_____ Zip Code:________
Your Signature: Printed Name:

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Address:

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State:

Zip Code:

Rev.12/05

This document is considered a public record under Oklahoma state law.