Form A-3B Application For A Permanent Certificate Of Consent To Self Insure {A-3B}

Form A-3B - APPLICATION FOR PERMANENT CERTIFICATE OF CONSENT TO SELF-INSURE FOR INTERIM SELF-INSURER. The California Code of Regulations, Title 8, Chapter 8, Subchapter 2, Article 2, provides the requirements for submitting a complete Affiliate and Subsidiary Self-Insurer's Application. The following forms and documents are required by this section to be included with the application. All required information must be submitted with the application form for the issuance of a permanent Certificate of Authority of Consent to Self-Insure and sent to: OSIP, 11050 Olson Drive, Suite 230, Rancho Cordova, Ca. 95670. Application Form and Attachments: • Completed Affiliate application (Form A-3B (1-2016)). • Certificate of Status in good standing for Affiliate/Subsidiary from Secretary of State. Resolution: • Master Certificate Holder’s Board resolution (Form A-5 (1-2016)). (NOTE: This form only needs to be submitted once for each Master Certificate Holder). Assumption and Guarantee: • Master Certificate Holder’s Board Parental Guaranty of Workers' Compensation Liabilities (Form A-4 (1-2016)).(NOTE: This form only needs to be submitted once for each Master Certificate Holder). Fees: No additional fees are required if the $500.00 application fee was submitted with the application for interim certificate. www.FormsWorkflow.com