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Annual Report Of Adjusting Locations DWC-857 - California
| Annual Report Of Adjusting Locations Form. This is a California form and can be used in General Workers Comp . |
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2013 ANNUAL REPORT OF ADJUSTING LOCATIONS To: State of California, Department of Industrial Relations Division of Workers' Compensation, Audit Unit ~ Attn: ARI Desk 160 Promenade Circle, Suite 340 Sacramento, CA 95834-2962 Self-Administered Insurance Company or Group COMPANY NAME Third-Party Administrator COMPANY FEIN Self-Administered Self-Insured Employer (private or public) STREET ADDRESS Self-Administered Joint Powers Authority CITY/STATE/ZIP Combination of any of the following, but only if administered under the same local management. (Check two or more): Self-Administered Insurance Company or Group CITY/STATE/ZIP Self-Administered Self-Insured Employer CONTACT NAME Third-Party Administrator TELEPHONE MAILING ADDRESS FACSIMILE E-MAIL Submitted by: Title: Date: Note: Insurer Groups (more than one underwriting company at the same location), third-party administrators, and combinations of the two must complete Part 2. A claims administrator, whose obligation to submit an Annual Report of Inventory has been waived in accordance with the California Code of Regulations, title 8, section 9701(i), must file an Annual Report of Adjusting locations by April 1 of each calendar year for the previous calendar year. Failure to timely submit an Annual Report of Adjusting Locations under California Code of Regulations, title 8, section 10104, Form DWC-857 Rev. 12/2012) (d) may be subject to penalty assessment of up to $500 per location. American LegalNet, Inc. www.FormsWorkFlow.com 2013 ANNUAL REPORT OF ADJUSTING LOCATIONS PART 2 For each individual underwriting company in an insurance group or client of a third-party administrator (whether a self-insured employer or an insurer), whose claims are administered at the adjusting location, complete the following: COMPANY NAME CONTACT NAME COMPANY FEIN TELEPHONE MAILING ADDRESS FACSIMILE CITY/STATE/ZIP CHECK ONE: Insurance Company E-MAIL Self-insured employer (private or public including joint powers authority) __________________________________________________________________________________________________________________ COMPANY NAME CONTACT NAME COMPANY FEIN TELEPHONE FACSIMILE MAILING ADDRESS CITY/STATE/ZIP CHECK ONE: Insurance Company E-MAIL Self-insured employer (private or public including joint powers authority) __________________________________________________________________________________________________________________ COMPANY NAME CONTACT NAME COMPANY FEIN TELEPHONE FACSIMILE MAILING ADDRESS CITY/STATE/ZIP CHECK ONE: Insurance Company E-MAIL Self-insured employer (private or public including joint powers authority) Complete and attach additional sheets if necessary. Form DWC-857 Rev. 12/2012) American LegalNet, Inc. www.FormsWorkFlow.com
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