Form S-2A Group Affiliate Member Interim Application {S-2A} | Pdf Fpdf Docx | California

 California   Workers Comp   OSIP 
Form S-2A Group Affiliate Member Interim Application {S-2A} | Pdf Fpdf Docx | California

Last updated: 4/16/2024

Form S-2A Group Affiliate Member Interim Application {S-2A}

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Description

Form S-2A - GROUP AFFILIATE MEMBER INTERIM APPLICATION. This form is used by an affiliate member of a self-insured group in California to apply for an interim certificate of consent to self-insure for workers' compensation claim liabilities. This certificate allows the affiliate member to be part of a group self-insurance plan for up to 180 days. The form includes details about the affiliate member's legal name, address, ownership type, incorporation state, federal tax ID number, nature of business, industry codes, payroll, and experience modification factor. It also requires the signature of the group authorized representative, indicating the group's financial responsibility for the affiliate member's workers' compensation claims during the interim period. www.FormsWorkflow.com

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