Affidavit Of Exempt Status Under Worker Compensation

AFFIDAVIT OF EXEMPT STATUS UNDER THE WORKERS’ COMPENSATION ACT

State of

Oklahoma

County of ______________)

I, ________________________________________ state under oath as follows:

I, _______________________ (Name of individual) operating as _____________________________

(independent contractor’s business name), have agreed to provide services to

_____________________________ (Contractor) during calendar year___________.

I have read, signed and attached the Exempt Status Fact Sheet and understand that an Independent Contractor

is one who engages to perform certain services for another, according to his own manner, method, free from

control and direction of his contractor in all matters connected with the performance of the service, except as to

the result or product of the work.

I understand that based upon the representations in this Affidavit of Exempt Status, I am requesting

________________________(Insert contractor’s name) to consider my business to be that of an independent

contractor; that I am not an employee under the Workers’ Compensation Act and the policy issued by

__________________________(Insurance Carrier); and that no premium be charged for the services

performed by my business during the policy year.

I am an independent contractor, not an employee of the contractor. I do not want workers’ compensation

insurance and understand that I am not eligible for Workers’ Compensation benefits.

I will obtain workers’ compensation and employers’ liability insurance for my employees if I have employees,

unless they are otherwise exempt from the requirements of the Workers’ Compensation Act.

I have read, signed and attached the Exempt Status Fact Sheet describing what is an Independent Contractor

and the information provided is not the result of force, threats, coercion, compulsion or duress.

I understand that the execution of the affidavit shall establish a rebuttable presumption that the executor is not

an employee for purposes of the Workers’ Compensation Act.

I understand that the execution of an affidavit shall not affect the rights or coverage of any employee of the

individual executing the affidavit.

I understand that knowingly providing false information on an Affidavit of Exempt Status Under the Workers’

Compensation Act shall constitute a misdemeanor punishable by a fine not to exceed One Thousand Dollars

($1,000.00).

Independent Contractor (Executor) Signature

Date ___________ Name________________________________ Title_________________________________

Signature________________________________

Business Name ________________________________

Notary Public

Signed and sworn to before me on this ____ day of __________, 20___ by ___________________________.

________________________________ My Commission Expires: _______________ My Commission #_________

Notary Public

This form is to be signed and notarized at the start of a job/project for this contractor and is good for the job/project or

any similar job/project performed for the contractor for one year from the date of notary.

Note: Employers who knowingly and willfully require an employee or subcontractor to execute an affidavit

when the employer knows that the employee or subcontractor is required to be covered under a workers’

compensation insurance policy shall be liable for a civil penalty of up to $1,000.00 per offense. (36 OS

§§924.5)

It is a crime to falsify the information on this form.

Edition 070106

Affidavit Of Exempt Status Under Worker Compensation - Uco

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