Oklahoma Supplemental Employment Verification Page 2
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1
2NAME
DATE OF
HOURS
STATUS
APPLYING FOR COVERAGE (YES)
FULL-TIME
WORKED
CODE
DECLINING COVERAGE (NO)
EMPLOYMENT
PER WEEK
ATTACH APPLICATION
1
Yes
No
2
Yes
No
3
Yes
No
4
Yes
No
5
Yes
No
Yes
6
No
7
Yes
No
8
Yes
No
9
Yes
No
10
Yes
No
11
Yes
No
12
Yes
No
13
Yes
No
14
Yes
No
15
Yes
No
16
Yes
No
17
Yes
No
18
Yes
No
19
Yes
No
20
Yes
No
21
Yes
No
22
Yes
No
23
Yes
No
24
Yes
No
25
Yes
No
In accordance with Oklahoma law, this form must be completed and submitted with a copy of your company’s Oklahoma
Employment Security Commission Report (OESC) for the most recent quarter filed. If additional space is needed, please use
another Supplemental Employment Verification form. All forms used must be signed and dated.
This will acknowledge that my place of business is located within the State of Oklahoma.
, hereby, certify that the information provided herein is true and correct to the best of my knowledge.
I
WARNING: Any person who knowingly and willfully makes a false or fraudulent statement or
representation in or relative to any application for insurance, or who makes any such statement to obtain
a fee, commission, money or benefit shall be guilty of a misdemeanor in accordance with Title 36, § 1204 of
the Oklahoma Statutes.
Print Name of Group Administrator : __________________________________________
Authorized Signature of Group Administrator : ___________________________________ Date : ______________________
BCBSOK reserves the right to request documents verifying the above information. In addition, it reserves the right to
reverify employment information at any time during the course of your contract with BCBSOK.
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