Okla. Stat. tit. 85, Rule 63 – Certificate of Coverage for Insurance

A. When an insurer issues a policy to provide workers' compensation benefits pursuant to the Workers' Compensation Act, the insurer immediately shall file, or cause to be filed, with the Court Administrator, a certificate of coverage. The certificate shall be in print format as follows, or may be submitted electronically to the Court in such form and manner as may be prescribed by the Court Administrator.
FRONT OF CARD
NAME OF INSURED EMPLOYER __________________________________________________
ADDRESS OF INSURED EMPLOYER'S PRINCIPAL PLACE OF BUSINESS_______________
______________________________________________________________________________
______________________________________________________________________________
PRINCIPAL OCCUPATION OF THE INSURED EMPLOYER BY NORTH AMERICAN INDUSTRY
CLASSIFICATION SYSTEM CODE - "NAICS CODE" __________________________________
CARRIER _____________________________________________________________________
POLICY NO. ___________________________________________________________________
ADDRESS OF ISSUING OFFICE __________________________________________________
______________________________________________________________________________
POLICY EFFECTIVE DATE _______________________________________________________
POLICY EXPIRATION DATE ______________________________________________________
FEDERAL EMPLOYER IDENTIFICATION NO. OF INSURED EMPLOYER _________________
______________________________________________________________________________
NAME OF CERTIFIED WORKPLACE MEDICAL PLAN (CWMP), IF ANY _________________ ______________________________________________________________________________
BACK OF CARD
I hereby certify that I have on this day delivered to the employer named on this card a workers' compensation certificate which covers all obligations of the insured under the Workers' Compensation Act of Oklahoma, wherever located, during the period shown on this card.
DATE ______________________________________
SIGNED BY _________________________________
TITLE ______________________________________
TELEPHONE NO. ____________________________
A certificate submitted in print format shall be on a 3" x 5" card of card stock, in 10 point type and signed by the issuing entity.
B. Any expense incurred by the Court or any party resulting from continuances necessitated by the failure of the respondent or its insurer to comply with this rule, may be assessed by the Court against the party responsible.
C. Each certified workplace medical plan shall file, and maintain, with the Court Administrator a current list of its network providers and dispute resolution form, for public disclosure. This filing requirement may be complied with by submission of the required information in writing, or electronically if approved in advance by the Court Administrator. Alternatively, the plan may notify the Administrator in writing of the appropriate InterNet web site address through which the required information may be accessed by the public electronically.