Workers' Compensation Premium Tax Report - Oklahoma Workers' Compensation Commission


Submit completed report to:
Insurance Division
1915 N. Stiles Avenue
Oklahoma City, OK 73105
(405) 522-3222 or In-State Toll Free (855) 291-3612
In accordance with 85A O.S., §206, as a mutual or interinsurance association, stock company or other insurance
carrier writing workers’ compensation insurance on risks located in this state, you are asked to provide the following
information to the Oklahoma Workers’ Compensation Commission NO LATER THAN _________________________:
Name of Carrier:______________________________________________________________________
Gross Direct Written Premium of Carrier Writing Workers’ Compensation Insurance on Risks Located in Oklahoma
for CALENDAR YEAR _________________________________:
This information will be used to determine the Oklahoma Option Insured Guaranty Fund assessment rate under 85A
O.S., §208 to be collected by the Oklahoma Workers’ Compensation Commission at the same time and in the same
manner as insurance premium taxes under Title 36 of the Oklahoma Statutes for deposit into the Oklahoma Option
Guaranty Fund.
Notice of the rate will be provided to each carrier and will be posted on the Commission’s web site at
The undersigned hereby certifies, UNDER PENALTY OF PERJURY, that he/she executed this report of his/her free
and voluntary will and as the duly authorized representative of the carrier named above, that the information and
amounts herein contained reflect a true, accurate and complete statement.
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.
Signature of Preparer
E-Mail Address
Name and Title (PLEASE PRINT)
Telephone Number ___________________________________________________________________________
Area Code and Number
Date _______________________________________________________________________________________
Direct questions regarding this form to the Oklahoma Workers’ Compensation Commission
at the address and telephone numbers listed above.
Revised 12-18-14


00 votes

Related Articles

Related forms

Related Categories

Parent category: Legal