Dear Member,

            The current ORWA Worker's Compensation Insurance policy will expire November 1, 2009.  We are contacting you in advance to allow sufficient time for completion of necessary paperwork prior to renewal.

            We must receive your enrollment form in our office by September 11th.  The form provides essential information for issuing you a quote.  Coverage cannot be renewed without the enrollment form, and the following information:

1.         A list of all employees, their social security number, their position and their 2008 W-2 or 1099 yearly salary.  Employees who resigned or were terminated in 2008 and new employees hired in 2009 should be included on this list.  Computations will be based on 2008 salaries, so please use W-2 and 1099 numbers when filling out the application.

2.         A copy of each employee's 2008 W-2 &/or 1099 (whichever applies).

3.         *Certificate of insurance from contract labor.  (Certificate must indicate it is for Worker’s Comp.)

*Note:  If a certificate of insurance is not provided for contract labor, contractor's salaries must be included in your system's payroll.

The “Affidavit for Independent Contractor Status” and “Exempt Status Fact Sheet” forms previously mailed to you, will continue to be a tool in helping you evaluate your relationship with your sub-contractors and identify whether they are independent contractors who do not require coverage under your policy. Both forms must be completed and the Fact Sheet must be attached to the Affidavit. Retain both as documentation of the status of all independent sub-contractors with whom you do business. These documents must be made available in connection with any audit of your worker’s compensation policy with CompSource Oklahoma. Please do not mail ORWA or CSO these forms. Also, do not include them on your renewal application. You can log on to the ORWA website www.okruralwater.org to download the Fact Sheet and Affidavit as well as any other forms you might need.

            Thank you for your support of the ORWA Worker's Compensation Program.  Please call Tina or Stephanie at 1-800-375-6792, if you have questions or need additional information.

Sincerely, 

Gene Whatley

Executive Director

Checklist

Application Page 1

Application Page 2

Enrollment Form

Exempt Affidavit and Fact Sheet