Employer/Employee Forms

Employee/Patient

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Employer/Client

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Accident/Injury Questionnaire

This questionnaire provides information to help process claims when an accident or injury has occurred.

The appropriate questionnaire is determined based on the location where the employer group receives administrative services.  For example, if the employer group is  located in Texas, but services are provided by the Oklahoma office, the Oklahoma Questionnaire should be selected.  Once the form is completed, return it to the address shown on the questionnaire.

Oklahoma Questionnaire 

Texas Questionnaire

Authorization of Designated Representative

This form allows you to authorize an individual to act on your behalf regarding a specific claim or multiple claims.  It must be signed by the claimant (the person who had the claim) and, if you feel it is necessary, the person you are authorizing to receive information and make decisions about appealing the claim.

Note:  The appropriate form is determined based on the location where the employer group receives administrative services. For example, if the employer group is located in Texas, but services are provided by the Oklahoma office, the Oklahoma Questionnaire should be selected. Once the form is completed, return it to the address shown on the questionnaire.

Authorization of Designated Representative-Oklahoma

Authorization of Designated Representative-Texas