Form A-2 Application For-A Public Entity Certificate To Self-Insurer {A-2}

Form A-2 - APPLICATION FOR CERTIFICATE OF CONSENT TO SELF-INSURE AS A PUBLIC AGENCY EMPLOYER SELF-INSURER. This form is used for public agency employers in California to apply for a Certificate of Consent to self-insure the payment of workers' compensation under California Labor Code Section 3700. It requires the employer to provide detailed information about the agency, including its legal name, contact information, and type of public entity. The form asks for details about the current workers' compensation program, claims administration, agency employer information, and agency safety program. Additionally, the form asks if the program will be supplemented by any insurance or pooled coverage. The application must include a properly executed governing board resolution, and an authorized official or representative must certify and sign the form to apply for the certificate. www.FormsWorkflow.com