CC- Form 36A "Affidavit of Exempt Status Under the Administrative Workers' Compensation Act" - Oklahoma

What Is CC- Form 36A?

This is a legal form that was released by the Oklahoma Workers Compensation Commission - a government authority operating within Oklahoma. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on January 2, 2019;
  • The latest edition provided by the Oklahoma Workers Compensation Commission;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a printable version of CC- Form 36A by clicking the link below or browse more documents and templates provided by the Oklahoma Workers Compensation Commission.

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Download CC- Form 36A "Affidavit of Exempt Status Under the Administrative Workers' Compensation Act" - Oklahoma

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CC-FORM-36A
THIS SPACE FOR COMMISSION USE ONLY
WORKERS’ COMPENSATION COMMISSION
1915 NORTH STILES AVENUE STE 231
OKLAHOMA CITY, OK 73105
File original and one (1) copy with the
Workers’
Compensation
Commission
(WCC) in-person or by mail, or file online at
www.ok.gov/wcc.
AFFIDAVIT OF EXEMPT STATUS UNDER THE
Must be accompanied by a nonrefundable
ADMINISTRATIVE WORKERS' COMPENSATION ACT
$50 filing fee payable to the WCC.
CHECKS WILL NOT BE ACCEPTED.
Type of Filing (check one):  Original Affidavit of Exempt Status - Expires at midnight two (2) years from the filing date.
 Renewal - Expires at midnight two (2) years from the expiration date indicated below.
If renewing a current Affidavit, provide: Affidavit # __________ and Expiration Date: _____________
I, ________________________________________, state under penalty of perjury, as follows:
1. I, ____________________________________ (Name of individual), in my individual capacity or operating as
_________________________________ (business name), have read, signed and attached the Exempt Status Fact Sheet and
understand the definition of "employee" and specific exceptions to that definition found in 85A O.S. §2(18). I also 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. A Contractor may be either (i) the owner of a project or job or (ii) an Independent
Contractor in any tier who has subcontracted with a subcontractor.
2. I understand that based upon the representations in this Affidavit of Exempt Status ("Affidavit"), I am reques�ng that the
recipient of this Affidavit consider my business to either (i) be exempt from the defini�on of “employee” or (ii) be that of an
independent contractor, and that no workers' compensa�on insurance premium be charged for the services performed by my
business. I do not want workers’ compensa�on insurance and understand that I am not eligible for workers’ compensa�on
benefits.
3. In the event changed circumstances make securing compensation pursuant to the requirements of the Administrative
Workers' Compensation Act necessary, I will execute and file a Cancellation of Affidavit of Exempt Status with the Workers'
Compensation Commission. 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 Administrative Workers’ Compensation Act.
4. The information I have provided is not the result of force, threats, coercion, compulsion or duress.
5. I understand that the execution of this Affidavit, if I am an independent contractor, shall establish a conclusive presumption
that I am not an employee for purposes of the Administrative Workers’ Compensation Act.
6. I understand that the execution of this Affidavit shall not affect the rights or coverage of any employee of the individual or
business executing this Affidavit.
7. I understand if any contractor or its insurer shall become liable under the Administrative Workers’ Compensation Act for the
payment of compensation due to a compensable work related injury of my employee(s), the contractor or its insurer may
recover from me the amount of such compensation paid or for which liability is incurred.
8. I understand that knowingly providing false information on an executed Affidavit of Exempt Status shall constitute a
misdemeanor punishable by a fine not to exceed One Thousand Dollars ($1,000.00).
Affiant Signature
I declare under PENALTY OF PERJURY that I have examined all statements contained herein, and to the best of my
knowledge and belief, they are true, correct and complete.
Affiant Name ______________________________________ Title ________________________ Phone _____________________
Business Name ____________________________________________________ Email ___________________________________
FEIN/EIN/TIN # _______________ Mailing Address ________________________________________________________________
Affiant Signature _________________________________________________________________ Date _____________________
Any person who commits workers’ compensation fraud, upon conviction, shall be guilty of a felony punishable by imprisonment, a fine or both.
It is a crime to falsify the information on this form.
Effective 1/2/19
CC-FORM-36A
THIS SPACE FOR COMMISSION USE ONLY
WORKERS’ COMPENSATION COMMISSION
1915 NORTH STILES AVENUE STE 231
OKLAHOMA CITY, OK 73105
File original and one (1) copy with the
Workers’
Compensation
Commission
(WCC) in-person or by mail, or file online at
www.ok.gov/wcc.
AFFIDAVIT OF EXEMPT STATUS UNDER THE
Must be accompanied by a nonrefundable
ADMINISTRATIVE WORKERS' COMPENSATION ACT
$50 filing fee payable to the WCC.
CHECKS WILL NOT BE ACCEPTED.
Type of Filing (check one):  Original Affidavit of Exempt Status - Expires at midnight two (2) years from the filing date.
 Renewal - Expires at midnight two (2) years from the expiration date indicated below.
If renewing a current Affidavit, provide: Affidavit # __________ and Expiration Date: _____________
I, ________________________________________, state under penalty of perjury, as follows:
1. I, ____________________________________ (Name of individual), in my individual capacity or operating as
_________________________________ (business name), have read, signed and attached the Exempt Status Fact Sheet and
understand the definition of "employee" and specific exceptions to that definition found in 85A O.S. §2(18). I also 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. A Contractor may be either (i) the owner of a project or job or (ii) an Independent
Contractor in any tier who has subcontracted with a subcontractor.
2. I understand that based upon the representations in this Affidavit of Exempt Status ("Affidavit"), I am reques�ng that the
recipient of this Affidavit consider my business to either (i) be exempt from the defini�on of “employee” or (ii) be that of an
independent contractor, and that no workers' compensa�on insurance premium be charged for the services performed by my
business. I do not want workers’ compensa�on insurance and understand that I am not eligible for workers’ compensa�on
benefits.
3. In the event changed circumstances make securing compensation pursuant to the requirements of the Administrative
Workers' Compensation Act necessary, I will execute and file a Cancellation of Affidavit of Exempt Status with the Workers'
Compensation Commission. 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 Administrative Workers’ Compensation Act.
4. The information I have provided is not the result of force, threats, coercion, compulsion or duress.
5. I understand that the execution of this Affidavit, if I am an independent contractor, shall establish a conclusive presumption
that I am not an employee for purposes of the Administrative Workers’ Compensation Act.
6. I understand that the execution of this Affidavit shall not affect the rights or coverage of any employee of the individual or
business executing this Affidavit.
7. I understand if any contractor or its insurer shall become liable under the Administrative Workers’ Compensation Act for the
payment of compensation due to a compensable work related injury of my employee(s), the contractor or its insurer may
recover from me the amount of such compensation paid or for which liability is incurred.
8. I understand that knowingly providing false information on an executed Affidavit of Exempt Status shall constitute a
misdemeanor punishable by a fine not to exceed One Thousand Dollars ($1,000.00).
Affiant Signature
I declare under PENALTY OF PERJURY that I have examined all statements contained herein, and to the best of my
knowledge and belief, they are true, correct and complete.
Affiant Name ______________________________________ Title ________________________ Phone _____________________
Business Name ____________________________________________________ Email ___________________________________
FEIN/EIN/TIN # _______________ Mailing Address ________________________________________________________________
Affiant Signature _________________________________________________________________ Date _____________________
Any person who commits workers’ compensation fraud, upon conviction, shall be guilty of a felony punishable by imprisonment, a fine or both.
It is a crime to falsify the information on this form.
Effective 1/2/19
EXEMPT STATUS FACT SHEET
Pursuant to 85A O.S., §36, any individual or business entity that is not required to secure compensation under the
requirements of the Administrative Workers' Compensation Act (AWCA) may execute an Affidavit of Exempt Status. Those
who are unsure as to whether they may lawfully submit an Affidavit of Exempt Status should seek competent legal
advice.
Employee: 85A O.S., §2(18): The definition of "employee" includes any person, including minors, in the service of an
employer under any contract of hire or apprenticeship, written or oral, expressed or implied. It excludes those whose
employment is casual and not in the course of the trade, business, profession, or occupation of his or her employer.
Additional, specific exceptions may be found in 85A O.S. §2(18)(b).
Independent Contractor: The AWCA does not define "independent contractor." Oklahoma law considers an independent
contractor to be one who engages to perform certain services for another, according to his or her own manner and method,
free from control and direction of his or her contractor in all matters connected with the performance of the service, except
as to the result or product of the work. Independent Contractors are not “employees” for purposes of the AWCA.
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.
1. The nature of the contract between you and the contractor. For example: Is there a writen contract where you agree that you
are an independent contractor? Are you a corpora�on or limited liability company? Do you maintain commercial general liability
insurance or other business insurance?
2. The contractor exercises very litle 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 specifica�ons for the job? Do you set your own work hours?
3. You are engaged in a dis�nct occupa�on or business for others. For example: Do you work for companies or individuals other
than the Contractor? Do you work for compe�tors of the Contractor? Does your business have a logo or uniform?
4. Your job is the kind of occupa�on where the work is usually performed by a specialist without supervision, and not under the
direc�on of the contractor. For example: Does the Contractor supervise your work?
5. Your occupa�on requires special skills, license, educa�on 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? Do you perform the
work at your business or the contractor’s business loca�on or jobsite? Do you wear a uniform supplied by the contractor?
7. The length and dura�on of the job does not show that you are really an employee. For example: Is this a one-�me 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 Contractor’s daily work? Have you ever been an employee of the Contractor? Do you work with other
people hired by the Contractor on the work you perform?
10. You do not consider yourself an employee of the contractor. For example: Will the Contractor withhold taxes or monies from
your payment? Have you ever been an employee of the Contractor? Have you or your employees ever filed an insurance claim
against the Contractor?
11. You do not have the right to terminate the rela�onship without liability. For example: If you quit before the job is finished, is
there a penalty?
It is a crime to falsify the information on this form.
Effective 1/2/19
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