Cc Form 2 – Fill Out and Use This PDF

The CC-2 Form serves as the Employer's First Notice of Injury, fulfilling a critical role in the workers' compensation process. It is designed for employers to report an employee's work-related injury or illness to the Workers’ Compensation Commission and their insurance carrier. By providing detailed information about the employee, the incident, and the injury, it initiates the claims process, ensuring that employees receive the necessary support and benefits.

To begin the process of reporting an injury and ensuring workers receive the compensation they deserve, click the button below to fill out the CC-2 Form.

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Cc Form 2 PDF Details

The Workers' Compensation Commission's CC-Form, a critical document within the framework of reporting workplace injuries, encapsulates a comprehensive approach for registering the initial notice of injury or illness as encountered by employees. This document, serving as a bridge between employers, insurance carriers, and the Commission itself, is designed to detail the specifics of an incident, capturing essential information such as the employee's full name, contact details, and social security number (with only the last digits disclosed for privacy reasons), alongside the date of the incident and subsequent employer notification timelines. Additionally, it dives into the length of employment, the occurrence specifics like time and place, nature of the injury or illness, and whether it was a result of a singular incident or cumulative trauma. The form further explores the response to the injury, including treatment details and any return-to-work status, which is vital for understanding the incident's impact on both the employee and the organization. Importantly, the CC-Form underscores the importance of accuracy and honesty in reporting, indicating severe repercussions for any form of fraudulent claims, thereby ensuring that both the employee's rights and the employer's obligations are clearly defined and protected. Implementation of this document is a testament to the administrative processes in place to facilitate workers' compensation claims, aiming to streamline the resolution of disputes and enhance the welfare of the workforce.

Question	Answer
Form Name	Cc Form 2
Form Length	1 pages
Fillable?	No
Fillable fields	0
Avg. time to fill out	15 sec
Other names	oklahoma form 2 workers comp, oklahoma form 2, form oklahoma 2, cc form 2

Form Preview Example

CC-FORM-

WORKERS’ COMPENSATION COMMISSION

THI“ “PACE FOR COMMI““ION U“E ONLY

NORTH “TILE“ AVENUE

USE BEGINNING

/ /

REGARDLESS OF DATE OF INJURY

OKLAHOMA CITY, OK 7

“e

d origi

al to Workers’ Co pe

saio

issio

to I

sura

e Carrier

EMPLOYER’S FIRST NOTICE OF INJURY

Please type or pri t. E ter all dates i

MM/DD/YY for

at.

Full Na

e of E

plo ee - LA“T, FIR“T, MIDDLE

plo ee E

ail Address

plete Address

Cit

“tate

)ip

Telepho e Nu

plo ee’s “o ial “e urit Nu

LA“T DIGIT“ ONLY

XXX-XX-________________________

Date of Birth

“e

gth of E

plo

e t: Years

Mo ths _______

Date of Hire:__________________________________

A erage Weekl Wage

upaio

des ripio

Was e plo

e t agree e t

ade i

Oklaho

YE“



NOTE: Mediation is available to help resolve certain workers’ compensation disputes. For information, call

0 22-8760 OR IN-STATE TOLL FREE (800) 522-8210.

Date of a ide

t or last e posure

e of a

ide t or e posure

AM  PM



Date E

plo er Noiied

Ti e

orkda

ega

AM  PM 

o’ lo k

Last date e

plo ee

orked

Has e

plo ee retur ed to

ork?

Did the e

plo ee die?

YE“

 NO

 If es, o

hat date ? __________________________

YE“

 NO

 If

es, o

hat date ?__________________________________________

O“HA Log Case #

Pla e of A

ide

t or O

urre

Cit

Cou

“tate:

I jur

Resulted fro

“i

gle I

ide



Cu ulai e Trau a



O upaio

al Disease



Nature of I jur

or Ill ess

Does e

plo ee pari ipate i

eriied orkpla e

edi al pla :

YE“  NO 

es,

e of CWMP:

Des ri

e a i iies

jur

urred

ith details of ho

e e

t o

urred. I

lude o je t or su

sta

hi h dire tl i

jured the e

plo ee.

Ide

part s

of od

ol ed i

jur

or ill ess

Full Na

e a

d address of Treai g Ph si ia

please

plete

plo er’s I

sura

e Carrier or O

Risk Group

Poli

/“elf-I sured Nu

Pho

Poli

Period: Fro

Address

Cit

“tate

)ip

plo er’s Na

e a

d Co

plete Address

Federal ID#

Pho e #

Address

Cit

“tate

)ip

T pe of

usi

ess E a

ple:

a ufa turi

g, food ser i e,

o stru io

NAIC“ Nu

T pe of O

ership:

Pri ate



“tate Go er



Cou t

Go er



Lo al Go er

e t



i istrai e Workers’ Co

saio

A t, 8

A O.S., § A

a :

perso

or e it

akes a

aterial false state

e t or

represe

taio

illfull

d k o

its or

eals a

g a

aterial i

for

aio

, or

ho e

plo

s a

de i e, s he

e, or

arii e,

ho aids a

d a

ets a

perso

for the purpose of:

tai i

eit or pa

t … shall

e guilt of a felo .

y perso

its

orkers’ o

saio

fraud, upo

i io

, shall

e guilty of a felo

y pu

isha le

y i

priso

e t, a i e

oth.

The u dersig ed here

de lares u der PENALTY OF PERJURY that the

ha e

e a

ed this

oi e a

d all state

tai ed herei

are true,

orre t

a d

plete, to the est of their k

ledge. The u dersig ed

eriies this

CC-For

as se t to the Workers’ Co

saio

issio

a d a op

thereof to the e

plo er’s i surer o

the date

oted

elo

“ig

“ig ature of Preparer

e a d Title of Preparer Please Pri

Telepho e Nu

Area Code a d Nu

Date

A CC-For		a	ust		e se t to the Workers’ Co		pe	saio
Co	issio		d	to	the e	ployer’s orkers’ o	pe	saio
i sura	e	arrier		ithi		days ater the date of re eipt of
oi e or k		o	ledge of death or i jury that results i					ore
tha three days’ a				se	e fro	ork for the i jured e	ployee.

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.

Created - -

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Cc Form 2 – Fill Out and Use This PDF

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