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Application For A Permanent Certificate Of Consent To Self Insure By An Interim Self Insurer A 4-5 - California
| Application For A Permanent Certificate Of Consent To Self Insure By An Interim Self Insurer Form. This is a California form and can be used in General Workers Comp . |
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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 Page 1 APPLICATION FOR A PERMANENT CERTIFICATE OF CONSENT TO SELF INSURE BY AN INTERIM SELF INSURER Read instructions before completing. All questions must be answered. If not applicable, enter "N/A". To the Director of Industrial Relations: The undersigned private employer hereby applies for a Certificate of Consent to Self Insure the payment of workers' compensation as provided by California Labor Code Section 3700. 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. 1. NAME OF COMPANY WITH MASTER CERTIFICATE OF CONSENT TO SELF INSURE: 2. INTERIM SELF INSURER APPLYING FOR A PERMANENT CERTIFICATE: 2. Interim Certificate Number: 1. Name of Company: 3. Street Address of Main Headquarters: 2. City: State: Zip + 4: 3. TO WHOM DO YOU WANT CORRESPONDENCE REGARDING THIS APPLICATION ADDRESSED? 2. Name: 2. Title: 2. Company Name: 2. Mail Address: 2. City: 2. Phone: ( ) State: FAX: ( ) Zip + 4: 4. BUSINESS STRUCTURE: 4. (a) CORPORATION 4. (a) State of Incorporation 4. (a) Date of Incorporation Month Day Year Yes No (b) PARTNERSHIP Yes No (b) Name and Designation of Partners 4. 4. (c) Sole Proprietor Form No. A4-5 (11/97) 2001 © American LegalNet, Inc. Yes No (d) Limited Liability Corporation Yes No Page 2 5. Number of California employees to be covered by the proposed addition to the self insurance plan: 6. Will the number of California employees covered under the proposed self insurance plan be materially 6. increased or decreased in the next 12 months? Yes No 6. If yes, by how many? Increase or Decrease 7. WORKERS' COMPENSATION EXPERIENCE IN CALIFORNIA: 7. Complete the following if the applicant's workers' compensation liabilities are insured in California under a 7. workers' compensation policy(ies): 7. Name of Current Carrier: 7. Policy Number: 7. Current Policy Termination Date: 7. Most recent three calendar years experience by policy period: Premium Before Dividend Experience Modification Losses Incurred Year Payroll Loss Ratio 7. If not previously insured, explain how workers' compensation liabilities were not covered: 8. ADMINISTRATION OF SELF INSURANCE PROGRAM FOR INTERIM CERTIFICATEHOLDER: 8. (a) Administration of workers' compensation self insurance claims will be by: Third Party Administrator Insurance Carrier Claims Department Self Administered by Employer 21. (b) Name of proposed administrator(s)/administrating agency(ies) who will be responsible for day-to-day 21. (b) administration of the workers' compensation self insurance program: 21. (a) Name (Person): 21. (b) Name of Agency/Carrier/Company: 21. (b) Address: 21. (b) City, State, Zip + 4: Title: 2001 © American LegalNet, Inc. Page 3 9. FILING FEE: Make your check payable to the Department of Industrial Relations--Self Insurance Plans for payment of the applicable filing fee. Filing Fee: Each private employer making application for a Certificate shall, at the time of filing the application, Filing Fee: pay a non-refundable filing fee on the following basis: Filing (a) For a single application, or the first of more than one application submitted together, the filing fee shall be $500.00. (b) For each additional application submitted with the first application, the filing fee shall be an additional $100.00. (c) For any subsequent application determined by the Manager to be necessary but not submitted with the original filing (c) of an application, the application will be considered a new application and the fee shall be an additional $500.00. 10. ATTACHMENTS: 10. (1) Original Certificate of Good Standing from the California Secretary of State dated not over 90 days. 10. (1) Available from the California Secretary of State, Corporate Filing Division 10. (1) 1500 Eleventh Street, Sacramento, CA 95814 -- phone (916) 653-6814 10. (2) Resolution to Become Self Insured by Interim Certificateholder's Board of Directors. 10. (3) Resolution Authorizing the Agreement of Assumption and Guarantee of Liabilities from Parent Corporation's 10. (3) Board of Directors. 10. (4) An Agreement of Assumption and Guarantee of Liabilities (executed by person authorized in Resolution Authorizing 10. (4) the Agreement of Assumption and Guarantee of Liabilities). 10. (5) Applicable Filing Fee. 2001 © American LegalNet, Inc. Model Corporate Resolution CORPORATE RESOLUTION AUTHORIZING APPLICATION TO THE DIRECTOR OF INDUSTRIAL RELATIONS, STATE OF CALIFORNIA FOR A CERTIFICATE OF CONSENT TO SELF INSURE WORKERS' COMPENSATION LIABILITIES At a meeting of the Board of Directors of , (enter name of corporation) a corporation organized and existing under the laws of the State of held on the day of 19 , , a quorum being present, the following Resolution was adopted: RESOLVED that the (enter titles of authorized corporate officers) be and they are hereby severally authorized and empowered to make application for a Certificate of Consent to Self Insure to the Department of Industrial Relations of the State of California, and to execute any and all documents required for such application, including the Instrument of Undertaking in furnishing security. I, Secretary of the said , the undersigned , a corporation, hereby certify that I am the Secretary of said corporation, that the foregoing is a full, true and correct copy of the resolution duly passed by the Board of Directors thereof at a meeting of said Board held on the day and at the place therein specified, and that said resolution has never been revoked, rescinded, or set aside, and is now in full force and effect. IN WITNESS WHEREOF: I HAVE HEREUNTO SET MY HAND AND THE CORPORATE SEAL OF SAID CORPORATION THIS DAY OF 19 . (SEAL) Secretary 2001 © American LegalNet, Inc. AGREEMENT This application is filed with the understanding and the agreement of the applicant herein that a Certificate of Consent to Self Insure, if granted, will be accepted subject to the authority of the Director of Industrial Relations to prescribe the regulations upon which said Certificate of Consent to Self Insure shall be granted or continued and subject to the full right and authority of the said Director of Industrial Rel
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