Form S-2B Application For Affiliate Certificate Of Consent To Self-Insure {S-2B}

Form S-2B - APPLICATION FOR AFFILIATE CERTIFICATE OF CONSENT TO SELF-INSURE AS A MEMBER OF A GROUP SELF-INSURER. This form is used by an employer in California to apply for a certificate allowing the employer to self-insure workers' compensation claims as part of a group self-insurance plan. This form collects detailed information about the employer, such as the legal name, ownership structure, existing corporate subsidiaries, current insurance coverage, and workers' compensation policies. It also asks for financial details, including net profit or loss for the last three years, as well as information about the workplace injury and illness prevention program. The application requires the signature of a group authorized representative, certifying the accuracy of the information provided, and must include required attachments such as related forms and agreements. REQUIRED ATTACHMENTS: • Groups Affiliate Member Interim Application Form S-2A (if not previously submitted). • Executed Resolution to be Self-Insured as a Member of Group Self-Insurer Form S-3. • Executed Indemnity Agreement Form S-4. www.FormsWorkflow.com