Form A4-50 Application For A Certificate To Administer WC Claims {A4-50}

Form A4-50 - APPLICATION FOR A CERTIFICATE OF CONSENT TO ADMINISTER WORKERS' COMPENSATION SELF INSURANCE CLAIMS. This form is is used by third-party administrators and administrative agencies seeking authorization from the California Department of Industrial Relations, Office of Self-Insurance Plans (OSIP) to administer workers’ compensation claims for permissibly self-insured employers. Filed under Labor Code section 3702.1, this application is required for new certificates, renewals, or the addition of reporting or adjusting locations. The form collects detailed information about the applicant’s business structure, ownership, managers, adjusting locations, and designated competent claims adjusters who have passed the Self-Insurance Administrator’s examination. It also requires disclosure of the self-insured employers serviced at each location and payment of applicable annual fees. www.FormsWorkflow.com