California > Workers Comp > General
Request For Interim Certificate - California
| Request For Interim Certificate 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 REQUEST FOR INTERIM CERTFICATE To: Mark B. Ashcraft, Manager Office of Self Insurance Plans 2265 Watt Avenue, Suite 1 Sacramento, CA 95825 Dear Mr. Ashcraft: Re: Request for Interim Certificate Please consider this request for issuance of an Interim Certificate for the following subsidiary or affiliate of our company, Date: , which holds Certificate of Consent to Self Insure No. : 1. Legal Name of Subsidiary/Affiliate: 2. State of Incorporation of Subsidiary/Affiliate: 3. Federal Tax Identification Number of Subsidiary/Affiliate: 4. Requested Effective Date of Interim Certificate: 5. Annual California Payroll of Subsidiary during the last 12 months or the latest 12-month period that payroll figures are available: $ Period reported: to If the Interim Certificate above is granted, on behalf of the Master Certificateholder named above, I hereby bind our company to be financially responsible to pay all workers' compensation claim liabilities arising out of the period of time the Interim Certificate is granted. Please forward the application forms to this office for completion. I am aware the Interim Certificate will remain in effect for 180 days and the application process must be completed within this time period. Sincerely, (Signature) Typed Name: Title: Company Name: Street Address: City: Phone: ( ) State: Fax: ( ) Zip + 4: 2001 © American LegalNet, Inc.
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