CompSource Oklahoma - Report an Injury

To file a workers’ compensation claim with CompSource Oklahoma please provide the following information, then click the “send form” button.

*denotes a required field.

*Full Name of Claimant (injured employee) - Last, First, Middle:

*Address:

*City: *State: *Zip:

Phone Number: *SSN:

*Date of Birth: *Sex: *Date of Hire:

Avg Weekly Wage: Occupation:

Was the employment agreement made in Oklahoma?

*Date of Accident or Last Exposure:

Time of Accident:

Date Employer Notified: Time Workday Began:

Last Date Employee Worked:

Has Employee Returned to Work? If yes, on what date?

Did Employee Die? If yes, on what date?

Place of Accident or Occurrence:
City: County: State:

*Nature of Injury or Illness:

Cumulative Trauma:
Carpal Tunnel
Respirator Illness
Heart Attack or Stroke
Hearing
Other

Single Incident Injury:
Sprain/Strain
Amputation
Heart Attack or Stroke
Burn
Other

*Identify Part(s) of Body Involved in Injury or Illness:

Full Name and Address of Treating Physician (please be complete):

*Describe activities when injury occurred with details of how event occurred. Include object or substance which directly injured the employee.

Is the validity of the accident/injury in doubt?

Supervisor's Name:

Witnesses to the Accident:

*Employer's Insurance Carrier or Own Risk Group:

If other, please list name, address and phone of Insurance Carrier:

*Policy/Self-Insured Number:

Policy Period: from: to:

*Name of Employer:

Address: Location Number:

City: *State: Zip:

Phone: Type of ownership:

Type of Business (example: manufacturing, food service, construction):

SIC Number:

Comments:

We must be able to contact you in order to process your claim. Please provide the following contact information:

*Your Name:
*Your Phone Number:
Your E-mail Address:
*Which category best describes you?

Please click only once to avoid transaction duplication.

A claims representative will contact you and process the claim as soon as possible.