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Application For A Certificate Of Consent To Self Insure By A Group Of Employers A4-3 - California
| Application For A Certificate Of Consent To Self Insure By A Group Of Employers Form. This is a California form and can be used in General Workers Comp . |
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COURT COUNTY .OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ......... .. : State of California Department of Industrial Relations Self Insurance Plans 2265 Watt Avenue, Suite 1 Sacramento, CA 95825 Phone (916) 483-3392 FAX (916) 483-1535 Index No. Page 1 : Plaintiff(s) -against: : Calendar No. JUDICIAL SUBPOENA : APPLICATION FOR A CERTIFICATE OF CONSENT TO SELF INSURE BY A GROUP OF EMPLOYERS : Read instructions before completing. Defendant(s) All questions must be answered. If not applicable, : . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .enter "N/A". Workers' compensation insurance must be maintained until certificate is effective. To the Director of Industrial Relations: The undersigned private group of employers hereby applies for a Certificate of Consent to Self Insure for itself and an Affiliate THE PEOPLE OF Self Insure for OF NEW YORK Certificate of Consent to THE STATEeach group member for the payment of workers' compensation as provided by California Labor Code Section 3700. TO The following information is submitted, under penalty of perjury, for the purpose of procuring a Certificate of Consent to Self Insure, which may be given upon proof, satisfactory to the Director of Industrial Relations, of ability to self insure and to pay compensation that may become due to employees. GREETINGS: 1. GROUP APPLICANT: 1. Name of Applicant Group: the Honorable GENERAL INFORMATION ON GROUP APPLICANT WE COMMAND YOU, that all business and excuses being laid aside, you and each of you attend before , at the Court located at County of 3. Street Address of Main Headquarters: in room , on the day of , 20 , at o'clock in the noon, and at any recessed or adjourned date, to testify and give evidence as a witness in this action on the part of the 2. City: State: Zip + 4: 1. Federal Tax Identification Number of Group: 1. State of Incorporation to comply with this Incorporation punishable as a contempt of court and will make you liable to Date of subpoena is Your failure Month Day Year the party Insurer must be a this subpoena was issued for a maximum penalty of $50 and all damages sustained 1. Group Self on whose behalf California corporation as required by California Code of Regulations, Title 8, Section 15470. as a result of your failure to comply. 2. TO WHOM DO YOU WANT CORRESPONDENCE REGARDING THIS APPLICATION ADDRESSED? Witness, Honorable 2. Name: in Court County, 2. Title: 2. Company Name: 2. Mail Address: 2. City: 2. Phone: ( ) , one of the Justices of the day of , 20 (Attorney must sign above and type name below) State: FAX: ( Attorney(s) for Zip + 4: ) 3. (a) Does the Group Applicant named in Question 1 presently have an active Certificate of Consent to Self Insure 3. (a) issued by the Director of Industrial Relations to self insure workers' compensation liabilities in California? Office and P.O. Address Telephone No.: Facsimile No.: 3. (b) Is this group applicant named in Question 1 applying for self insuranceE-Mail Address: first time? in California for the Mobile Tel. No.: 3. (a) Yes No If yes, enter Certificate Number: Form No. A4-3 (1/94) Yes No American LegalNet, Inc. www.USCourtForms.com COURT COUNTY .OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ......... .. : : 4. Reincorporation 4. Merger -against4. Change in Identity 4. Majority Change in Ownership 4. New member additions to the Group Index No. Page 2 Calendar No. 4. Is this application being submitted by the group applicant named in Question 1 because of any of the following: Plaintiff(s) Yes Yes Yes Yes Yes : No :No No No : No JUDICIAL SUBPOENA : 4. If yes, submit a copy of legal documents regarding reincorporation, merger, change in identity or sale with this 4.application and explain below: Defendant(s) : ...................................................... 4. THE PEOPLE OF THE STATE OF NEW YORK TO GREETINGS: (Continue on additional page if necessary.) 5. (a) What is the nature of the business of the members of the applicant group named in Question 1? WE COMMAND YOU, that all business and excuses being laid aside, you and each of you attend before , the Honorable at the Court located at County of in room , on the day of , 20 , at o'clock in the noon, and at any recessed or adjourned date, to testify and give evidence as a witness in this action on the part of the 5. (b) What is the primary 4-digit North American Industry Classification System Code (NAICS Code, predecessor to SIC 5. 5. (b) Code) for the members of the applicant group named in Question 1? Witness, Honorable , one of the Justices of the 5. (b) named in Question 1? NAICS Code: Your failure to comply with this subpoena is punishable as a contempt of court and will make you liable to the party on whose behalf this subpoena was issued for a maximum penalty of $50 and all damages sustained as a result of your failure to comply. Court in County, day of , 20 6. What is the proposed date of commencement of your Group Self Insurance Program in California? Upon Approval by Director Other Date: (Attorney must sign above and type name below) 7. (a) Number of California employees to be covered by the proposed group self insurance plan: Attorney(s) for 7. (b) Will the number of California employees covered under the proposed group self insurance plan be materially 7. (b) increased or decreased in the next 12 months? Yes 127. ( If yes, 6. (c) No Increased or Decreased Office and P.O. Address by how many? Telephone No.: Facsimile No.: E-Mail Address: Mobile Tel. No.: American LegalNet, Inc. www.USCourtForms.com COURT COUNTY .OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ......... .. : Index No. Page 3 8. Attach an original Certificate of Good Standing from the California Secretary : State for the applicant group of Calendar No. 8. named in Question 1. Plaintiff(s) -against- : : : : JUDICIAL SUBPOENA (Attach original Certificate of Good Standing dated not less than three months from the date of the submission of this application.) Defendant(s) : ...................................................... THE PEOPLE OF THE STATE OF NEW YORK TO GREETINGS: WE COMMAND YOU, that all business and excuses being laid aside, you and each of you attend before , the Honorable at the Court located at County of in room , on the day of , 20 , at o'clock in the noon, and at any recessed or adjourned date, to
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