Form A312d - Statement Of Exemption From The Workers' Compensation Act Affidavit
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1State of Oklahoma
Statement of Exemption from The
Office of Management and Enterprise Services
Workers’ Compensation Act
Division of Capital Assets Management
Affidavit
Construction and Properties
Pursuant to Attorney General Opinion #07-8, the exemption from the Workers' Compensation Act provided for in 85 O.S. 2011, § 311.5 applies only to
employers who are natural persons, such as sole proprietors, and does not apply to employers who are entities created by law, including but not
limited to corporations, partnerships and limited liability companies.
STATE OF
)
Project Name:
) ss
COUNTY OF
)
CAP Project No.:
I, the undersigned, am exempt from the Oklahoma Workers’ Compensation Act and hereby waive any claim against the State of
Oklahoma, including but not limited to, the Construction and Properties Department of the Office of Management and Enterprise
Services, Division of Capital Assets Management and the using agency, and/or their agents, and I assume all responsibility for
accidents, injuries or losses incurred by me or one of my employees, subcontractors or suppliers while in connection with any activity
conducted with performance of the contract for construction, thereby releasing the aforesaid from any responsibility under the
Workers’ Compensation laws of the State of Oklahoma.
Claimed Exemption:
Title 85, Section 311.5
Other:
Is this a “Doing Business As?”
Yes
No
(Company Printed Name)
(Street Address)
(City, State, Zip)
Subscribed and sworn to before me this
day of
,20
(Authorized Representative Signature)
(Signature of notarial officer)
(Authorized Representative Printed Name)
My Commission Expires:
(Authorized Representative Printed Title)
My Commission #:
(Seal)
DCAM/CAP - FORM A312D (08/2015)
STATEMENT OF EXEMPTION FROM THE WORKERS’ COMPENSATION ACT AFFIDAVIT PAGE 1 OF 1
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