Oklahoma Supplemental Employment Verification
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2Oklahoma Supplemental Employment Verification
To be used with the OESC report or other proof of wages documentation
Employer’s Name
SIC Code
Employer’s Address
City
State
ZIP Code
•
Proof-of-wages documentation is required when enrolling new small groups. We encourage employers to
submit the most recent quarterly Wage and Tax Report (commonly referred to as the OESC report). If a
current OESC report is not available, we will accept payroll reports containing details similar to those found
on a Wage and Tax Report.
•
You must submit this form (Oklahoma Supplemental Employment Verification-OSEV) when you have hired
or are compensating employees other than those found on your proof-of-wages documentation.
•
On your proof-of-wages documentation, please mark each employee listed with the appropriate status code
from the list below.
Additionally, the status codes below should be used on page 2 of this form.
•
Each full-time employee must complete an enrollment application indicating whether they are requesting or declining coverage.
STATUS CODES
F
Full-time employee who works 24 or more hours per week
P
Part-time employee who works less than 24 hours per week
I
Independent contractor
O
Owners, partners and officers
S
Seasonal employee or temporary employee
D
Totally disabled employee
C
Continued employee under state or federal law
T
Terminated, no longer employed by the company
W
Full-time employees in waiting period
On page 2 of this form please list employees not found on the OESC report or payroll report.
•
New employees who work a minimum of 24 hours per week
Owners, partners and officers
•
Independent contractors
•
Other
•
(Please define employees who fall into this category so BCBSOK may determine if they are eligible for
coverage.) All individuals should be listed even if they decline coverage.
A Division of Health Care Service Corporation, A Mutual Legal Reserve
Company, An Independent Licensee of the Blue Cross and Blue Shield Association
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