FORM 3' A 1915 NORTH sens mm a a 0 cases l: MA OK 6105431 Nmke CCmcEnsallchaul' =lmse areas emneenele ,nns A JUL 25 2012 en, ale venenenen WQRKERS non COMPENSATIO "12. 03215enemy as Lee 7 7 'Nam: :flcloyel Nels Medixiun ix avzilable (o addrux mum Walkerj' puns. For inlormarinn, all (405) 52243750 or ln-Sme Yul! Free (9007 512-3210. JP/ease we or Lerg'r E'flp'flvme Occupzllon years Was Aid-yup nymenl egyeemer lr 'Oklahnma'r vEsD NO Ea": n1 "seem, en es "unease Dale s. yennenon mm esnea mm nW Occurveu mm: play enxllaCumulalwe lraumalnjury: a/ at snglenneen Camel-ye- en Desoempe 50"hebcdy lnyuvedorafieclec Cnycamy Slele I Wnel we name :l me nqu av ss aelalls Ir|ury occer'ea Jl'eclly mm you lglelelormeclcaye Earls lelelcrmeem a so momr's cl lne W5 Ncl-ce Clalm 'ar Camaersallan" N3 v5 Ale yo>> 5 plevluusly lmaalled pelscn flue KC a walkers eelneensenen mqu nbkus and appalam mensan was vau may he enlued la senelns lo! Cunblnen msemlmes agalns'l m2 Mennle lr'lur/ Trus: A ll" agalns: .ne \nulnple ln'my Tlle 5.1m may as cammenced by ulan 3 'me 3; mm lne kaels Ccmpellsahun Com Tveanng (lull name). Adcress my see Cal-plcle Au :enplele Szrael Acuress ll: Graven: l- Any person lempornry ry an employer m. empluyer's lnsuranc: camel snell seven (7) days reporl .n no me emplaysr or Insurance Gamer eny enenge malenel {ad or me amuum el lne employee is vecelvmg or any change 'ln me employee's employmenl slams. eccumng dunng lne pevlod el recelpl el such nenems, Any pevscn wha wavkevs' lyaua, upon snall be gulHy a! leluny Upon (ms Nollce al Accidemal lniury And Fm Campensallnn. permls ls glven lo lne ol me Walkers Campens calm, me lnsurence Cammissmner. me Allumey Genera'y Name al clalmam atlm'ley replesemec 7 7 7 Allorney erlnelraesigneesmexemlneall name my Mm 35"" mane! we noticay and any miller vul In me name he 7 ,7 7 granled lo lne abave persons au'hurlze: (hem access madlcal Malhng Aeeress records pursuznl 75 0. 5w, lnelumng wawen e4 any granled by law cancemlng made la a or healm care 777. provlder knowledge Dblalned by such a! mom care CW we 1W by personal examlnallun larm ls nol "Handed for use as a zumnnzilmn, Numan sneu be ln walve, av Impall any ellmenllary pn lege recognized by law. l'elea'lcne Ides/ya under pens/1y cl perjury mall nave exammed 0115 name and claim m: tampensau'on and all Siam/Went: canlelneu harem are me sweet and complete lo the best amy knowledge a Slgned :nls Clewenv we 2' Anome nazsn