Revised --1 Page 1 of 3 STATE OF OKLAHOMA WORKERS222 COMPENSATION COMMISSION 1915 N STILES AVE STE 231 OKLAHOMA CITY, OKLAHOMA 73105 (405)522-3222 or In-State Toll Free (855) 291-3612www.ok.gov/wcc APPLICATION FOR CERTIFICATE OF NONCOVERAGE Pursuant to 85A O.S., 24736 and O.A.C. 810:25:5:1, a request for a Certificate of Noncoverage requires the following: i)Submit a signed and completed Application for Certificate of Noncoverage on the form prescribed by theCommission, to the address listed below. The application must be notarized and signed by the applicantunder penalty of perjury; andii)Pay to the Commission a nonrefundable application fee of Fifty Dollars ($50.00) with the Application forCertificate of Noncoverage. Payment may be submitted through the Commission222s website,www.ok.gov/wcc . See 223Related Topics224 on the website222s 223Home Page224 for more information about online payments. Incomplete, illegible or unsigned applications or applications received without payment OR proof of online payment, will not be processed. Once the Commission approves an application, it will mail a Certificate of Noncoverage to the applicant at the address provided on the application. A Certificate of Noncoverage is issued for a two year period, and must be renewed by application to the Commission. If the applicant222s status changes during the effective period of the certificate, causing the applicant to no longer be eligible for the Certificate of Noncoverage, the applicant must report this change of status to the Commission within thirty (30) days of the status change. A Certificate of Noncoverage is valid only for a single applicant. If a spouse or other partners of a partnership desire a Certificate of Noncoverage, each partner must apply for his or her own Certificate of Noncoverage. If the applicant has employees, workers' compensation coverage is required for such employees in accordance with 85A O.S., 247 38. The Certificate of Noncoverage shall not affect the rights or coverage of any employees of the sole proprietor or of the partnership. Completed applications with the original signature of the applicant and notary public must be delivered to the Commission via mail, courier, or in person, to the following address. Emailed or scanned applications will not be accepted. OKLAHOMA WORKERS' COMPENSATION COMMISSION 1915 N. STILES AVENUE, STE 231 OKLAHOMA CITY, OK 73105 CC - FORM - 36 American LegalNet, Inc. www.FormsWorkFlow.com Revised --1 Page 2 of 3 APPLICATION FOR CERTIFICATE OF NONCOVERAGE NOTE: A nonrefundable application fee of Fifty Dollars ($50.00), made payable to the Oklahoma Workers' Compensation Commission, MUST accompany the application unless the fee has been paid online through the Commission222s website. 85A O.S., 24736. Certificates may only be issued to applicants who meet the requirements in question 9 below. Date: By completing, signing, and submitting this application and the accompanying affidavit, the applicant elects not to be covered by the Administrative Workers' Compensation Act (AWCA) and not be deemed an employee thereunder. 1.*Applicant222s Name 2.*Applicant222s Social Security Number 3.*Applicant222s Street Address (Apt # or Suite #) 4.*Applicant222s City, State, and Zip 5.Name of the Applicant222s Business (if any) 6.Street Address of Applicant222s Business (if any) (Apt # or Suite #) 7.City, State, Zip of Applicant222s Business (if any) 8.Federal ID Number of Applicant222s Business (if any) 9.*I declare I am doing business in Oklahoma in one of the following manners: (mark applicable option): GSole Proprietor - An individual or married couple in business alone or the sole member of a Limited LiabilityCompany that is treated as a disregarded entity for federal income tax purposes. GPartner of a Partnership - Any partner of a partnership or any member of a Limited Liability Company that istreated as a partnership for federal income tax purposes. If a partner of a partnership, what percentage of thecompany do you own? An individual who is not a "sole proprietor" or "partner of a partnership," as defined above and in accordance with Commission Rule 810:25-1-2, is not eligible for a Certificate of Noncoverage and should NOT submit this application or the NONREFUNDABLE application fee. 10.Effective date of Applicant222s business . 11.Desired effective date (Certificates will not be issued with an effective date prior to the date the Commission receivesthis application) . *Indicates required field CC - FORM - 36 American LegalNet, Inc. www.FormsWorkFlow.com Revised - Page 3 of 3 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. Signed this day of , 20. *Printed Applicant Name *Applicant Signature (Must be signed in the presence of a notary public) *Applicant Mailing Address (Including any Apt # or Suite #) *Applicant City, State, ZIP Applicant Telephone Number, including Area Code Applicant E-mail Address *Indicates required field. STATE OF OKLAHOMA COUNTY OF Before me, the undersigned authority, on this day appeared, (Applicant222s Name) who acknowledged that he/she executed the foregoing for the purposes and consideration therein stated. WITNESS by my hand and my notarial seal this day of , 20. Notary Public Signature My Commission Expires: Administrative Workers222 Compensation Act, 85A O.S., 2476(A)(1)(a): 223Any 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 205 shall be guilty of a felony.224 Any person who commits workers222 compensation fraud, upon conviction, shall be guilty of a felony punishable by imprisonment, a fine or both. CC - FORM - 36 American LegalNet, Inc. www.FormsWorkFlow.com