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Affidavit Of Exemption - Oklahoma

Affidavit Of Exemption Form. This is a Oklahoma form and can be used in Workers Comp .
 Fillable pdf Last Modified 3/18/2014
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AFFIDAVIT OF EXEMPT STATUS UNDER THE WORKERS' COMPENSATION ACT State of Oklahoma County of ______________) I, ________________________________________ state under oath as follows: 1. 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. The information I have 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 will be responsible for any taxes, penalties, interest or liabilities assessed against the contractor if I am determined by a governmental agency to be the employee of the Contractor. I understand that knowingly providing false information on an Affidavit of Exempt Status Under the Workers' Compensation Act shall constitute a felony. Independent Contractor (Executor) Signature Date ___________ Name________________________________ Title_________________________________ 2. 3. 4. 5. 6. 7. 8. 9. 10. 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 ยงยง924.5) It is a crime to falsify the information on this form. Edition 21014 American LegalNet, Inc. www.FormsWorkFlow.com EXEMPT STATUS FACT SHEET An independent contractor is defined by law as one who engages to perform certain services for another, according to his own manner and 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. Below are statements to help you decide if you are an independent contractor. No one statement is controlling, and your status is based on all the facts in your situation. If a statement describes your situation, then check the box. If at least six of the statements below do not describe your business, you should not sign the attached Affidavit of Exempt Status Under the Workers' Compensation Act. 1. The nature of the contract between you and the contractor shows you are independent from the contractor. For example: Is there a written contract where you agree that you are an independent contractor? Are you a corporation or limited liability company? Do you maintain commercial general liability insurance or other business insurance? 2. The contractor exercises very little control over your work. For example: By the agreement, can the contractor exercise control on the details of the work or your independence? Do you exercise control over most of the details of the work? Do you create plans or specifications for the job? Do you set your own work hours? 3. You are engaged in a distinct occupation or business for others. For example: Do you work for companies or individuals other than the Contractor? Do you work for competitors of the Contractor? Does your business have a logo or uniform? 4. Your job is the kind of occupation where the work is usually performed by a specialist without supervision, and not under the direction of the contractor. For example: Is your work supervised by the Contractor? 5. Your occupation requires special skills, license, education or training. 6. The contractor does not supply the things needed to perform your job such as the tools and the place of work. For example: Do you supply any of the materials or tools for the work? Do you operate a vehicle owned by the contractor? Was the work performed at your business or the contractor's business location or jobsite? Do you wear a uniform supplied by the contractor? 7. The length of the job and how long you have worked for the Contractor does not show that you are really an employee. For example: Is this a one-time job, or will you be doing this for the contractor regularly? 8. You are paid as a separate contractor, not as an employee. For example: Do you invoice the Contractor for your services? Are you paid by the job? Do you file a federal income tax return for your business? Do you expect to receive an IRS Form 1099 from the Contractor? Does the Contractor pay your expenses? 9. Your work is not the regular business of the employer. For example: Is your work customarily done in the Contractor's line of business or as part of the Contr
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