The following certificate shall be executed by the carrier or its agent issuing the workers' compensation insurance or the approved own risk company and filed immediately with the Court:

FRONT OF CARD

Carrier Name or
Own Risk # ___________________________________________________________
INSURED_____________________________________________________________
ADDRESS____________________________________________________________
CARRIER_____________________________________________________________
POLICY NO.___________________________________________________________
ADDRESS OF ISSUING OFFICE _________________________________________
_____________________________________________________________________
EFFECTIVE (TIME & DATE)______________________________________________
EXPIRES (TIME & DATE)________________________________________________
FEDERAL EMPLOYER IDENTIFICATION NO. _______________________________

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 _______________________________________________________________

The notice shall be printed on 3x5 card of card stock. The certificate shall be printed in 10 point type and signed by the issuing entity, including the address of the employer's principal place of business in Oklahoma.

Any expense incurred by the Court or any party resulting from continuances necessitated by the failure of the respondent or its insurance carrier to comply with this rule, may be assessed by the Court against the party responsible.

Adopted by order of the Supreme Court, 1997 OK 130 , eff. November 1, 1997; Amended by order of the Supreme Court, 2000 OK 13 , eff. April 15, 2000.