Form A-3A Private Affiliate Interim Application {A-3A}

Form A-3A - PRIVATE / PUBLIC INTERIM APPLICATION. This form is used for applying for an interim certificate for a private affiliate or subsidiary in the State of California. The certificate is issued by the Department of Industrial Relations' Office of Self-Insurance Plans and allows a private or public entity to self-insure for workers' compensation liabilities. The form requires the applicant to provide details such as the master certificate holder's name, legal name, federal tax identification number, and principal California address. The interim certificate is valid for 180 days, during which the self-insured employer agrees to be financially responsible for paying all workers' compensation claim liabilities for the applicant. An authorized representative of the employer must sign and provide contact details. www.FormsWorkflow.com