Please fill in the form below as completely as possible. (*) denotes a required field.
Once you submit the form, the information will be sent to the claims company. The claims company will submit the form 2 to the Workers Compensation court on your behalf.
Please only submit forms for policies insured by BancInsure, Inc and written through COMP Risk Management, Inc. Forms for other carriers will not be accepted.
To view your claim you must have Adobe Reader installed. click here to download. |
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Employee last name is required.
First Name of Employee required
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Enter employee information below.
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| Last Name of Employee (*) |
Employee last name is required. |
| First Name of Employee (*) |
First Name of Employee required |
| Middle Name of Employee (*) |
Middle Name of Employee Required |
| Employee Street Address (*) |
Address is required. |
| Employee City (*) |
Employee City Required |
| Employee State (*) |
Employee state is required. |
| Employee Zip Code (*) |
Zip Code is required. |
| Employee Telephone Number-(Include Area Code) (*) |
Invalid employee phone number |
| Date of Birth (all dates must be mm/dd/yy format) (*) |
Invlaid date of birth |
| Sex (*) |
Invalid employee sex. |
| Length of Employment-In Years and months |
| Years (*)The lenght of years employment is required. |
MonthsLength of employment months is required. |
| Average Weekly Wage (*) |
Invalid Average weekly wage |
| Occupation (Job Description) (*) |
Invalid occupation |
| Employee Social Security Number (*) |
Social Security Number is required. |
NOTE: Mediation is available to address certain worker's compensation disputes. For Information, call (405) 522-8760 or in state toll free at (800) 522 - 8210
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Enter information about the accident below.
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| Date of Accident or Last Exposure (*) |
Invalid DateLastExposure |
| Time of Last Exposure |
Invalid Input |
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Invlaid AccidentLastExposureAmPm |
| Date Employer Notified |
Invalid AccidentDateEmployerNotified |
| Time Workday Began |
Invalid Input |
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Invalid Input |
| Last Date Employee Worked (*) |
Invalid Input |
| Has employee returned to work (*) |
Invalid AccidentEmployeeReturnedWork |
| When did the employee return to work? |
Date employ returned to work is required. dd.mm.yyyy |
| Did the employee die? |
Invalid AccidentEmployeeDied |
| Date Employee Died |
Invalid AccidentDateEmployeeDied |
| OSHA Log Case Number- (if applicable) |
Invalid OSHALogCaseNumber |
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Place of Accident or Occurrence |
| City (*) |
Invalid AccidentCity |
| County |
Invalid AccidentCounty |
| State (*) |
Invalid AccidentState |
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Injury Resulted from: |
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Invalid SingleIncidentCumulativeTrauma |
| Does employee participate in a certified workplace medical plan: |
Invalid EmployeeParticipateCertifiedWorkplaceMedicalPlan |
| If yes, name of certified workplace medical plan: |
Invalid NameCWMP |
| Nature of Injury or Illness (*) |
Invalid AccidentNatureInjury |
| Describe activities when injury occurred with details of how event occurred. Include object or substance which directly injured the employee. (*) |
Invalid AccidentActivities |
| Identify part(s) of body involved in injury or illness (*) |
Invalid AccidentBodyPartsInvolved |
| Full Name and address of Treating Physician (please be complete) (*) |
Invalid AccidentTreatingPhysician |
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Enter the employers information below.
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| Employment Agreement in OK |
invalid EmploymentAgreementInState |
| Employer Name (*) |
Missing Employer Name |
| Employer Address (*) |
Missing Employers Address |
| Employer City (*) |
Missing Employers City |
| Employer State |
Invalid Employers State |
| Employer Zip Code (*) |
Missing Employers Zip Code |
| Employer Federal Id |
Missing Employers Federal Id |
| Employer Phone (include area code) (*) |
Missing Employers Phone Number |
| Employer Type of Business (*) |
Missing Employers Type of Business |
| Employers Ownership |
Invalid EmployersOwnership |
| SIC Number |
Missing Employers SIC Number |
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Enter your policy information below.
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| Policy Number |
Invalid policyselfinsurednumber |
| Policy Period From |
Invalid policyperiodfrom |
| Policy Period To |
Invalid policyperiodto |
Upon filing this notice of injury, permission is given to the Administrator of the Worker's Compensation Court, the Insurance Commisswioner, the Attorney General, a District Attorney or their designees to examine all records relating to the notice, any matter contained in the notice, and any matter relating to the notice.
Any person receiving temporary disability benefits from an employer or the employer's insurance carrier shall promptly report in writing to the employer or insurance carrier any change in a material fact or the amount of income the employee is receiving or any change in the employee's employment status, occurring during the period of receipt of such benefits.
I hereby declare under penalty of perjury that I have examined this notice, and to the best of my knowledge and belief, they are true correct and complete. Any person who commits worker's compensation fraud, upon conviction, shall be guilty of a felony.
I hereby certify that this Form 2 will be submitted to the claims company, Claims & Risk Services, to be forwarded to the Worker's compensation Court and to the insurer.
SUBMISSION OF THIS FORM IS NOT AN ADMISSION OF LIABILITY
A Form 2 must be sent to the Workers Compensation Insurance Carrier within 10 days, or a reasonable time thereafter, of learning that an employee has suffered an accidental injury which results in lost time beyond the shift, or requires medical attention away from the work site, fatal or otherwise. Form 2s filed with the Worker's Compensation Court are confidential and not subject to public disclosure except as authorized by law.
I hereby certify that this Form 2 will be submitted to the claims company, Claims & Risk Services, to be forwarded to the Worker's compensation Court and to the insurer. |
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E Mail Address | Invalid email
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Signed this day | This is a required field. Please select the day submitted.
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Month Submitted | Required Field. Please select the Month submitted
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Year Submitted | Required Field. Please select the year submitted
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Prepared By | This is a required field to be filled out by the person preparing this document.
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Preparer Title | Invalid Input
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