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WORKERS’ COMPENSATION PREMIUM TAX REPORT

Submit completed report to:

OKLAHOMA WORKERS’ COMPENSATION COMMISSION

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.

Signed______________________________________________________________________________________

Signature of Preparer

E-Mail Address

By_________________________________________________________________________________________

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

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