Oklahoma Work Comp Affidavit
Oklahoma Work Comp Affidavit
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I declare I am a Sole Proprietor G or Partner of a Partnership G (mark applicable option) engaged as such in
Oklahoma.
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Please note:
A Certificate of Noncoverage is for a period of two years, and must be renewed by application to the Commission. If the
applicant=s status changes during the effective period of the certificate, which makes the applicant no longer eligible for
the Certificate of Noncoverage, the applicant must report this change of status to the Commission within thirty (30) days
of the change.
A Certificate of Noncoverage is valid only for the applicant. If other partners of a partnership desire a Certificate of
Noncoverage, then they must apply for their own.
If the applicant has employees, workers= compensation coverage for such employees in accordance with 85A O.S., '38 is
required. The Certificate of Noncoverage shall not affect the rights or coverage of any employees of the sole proprietor
or of the partnership.
In consideration of the approval of this application, the applicant hereby expressly agrees to comply with all applicable
statutes, and with the Rules of the Workers= Compensation Commission.
CC- FORM - 36
AFFIDAVIT FOR CERTIFICATE OF NONCOVERAGE
To the Oklahoma Workers= Compensation Commission:
You are hereby notified that the undersigned, who has submitted the attached Application for a Certificate of
Noncoverage is a sole proprietor or partner of a partnership and, being engaged as such in the State of Oklahoma, elects
to be excluded as an employee and from the mandatory insurance requirements of the Oklahoma Administrative Workers=
Compensation Act (AWCA).
I declare under penalty of perjury that I have examined this Application for Certificate of Noncoverage and all statements
contained therein, and to the best of my knowledge and belief, they are true, correct and complete.
Administrative Workers Compensation Act, 85A O.S., 6(A)(1)(a): Any person or entity who makes any material false statement or
representation, who willfully and knowingly omits or conceals any material information, or who employs any device, scheme, or artifice, or who
aids and abets any person for the purpose of: (1) obtaining any benefit or payment shall be guilty of a felony.
Any person who commits workers compensation fraud, upon conviction, shall be guilty of a felony punishable by imprisonment, a fine or both.