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

State of California Department of Industrial Relations Office of Self Insurance Plans 11050 Olson Drive, Suite 230 Rancho Cordova, Ca. 95670 Phone (916) 464-7000 Fax (916) 464-7007 Our File: APPLICATION FOR A CERTIFICATE OF CONSENT TO ADMINISTER WORKERS' COMPENSATION SELF INSURANCE CLAIMS ×NSTRUCTIONS: All questions below must be answered. If not applicable, enter "N/A". The undersigned administrative agency hereby applies for a Certificate of Consent to Administer workers' compensation claims for permissibly self-insured employers in accordance with the provisions of California Labor Code Section 3702.1. 1. Date: 2. Type of Application: New Addition of Reporting Location(s) Only Renewal of Existing Certificate to Administer No.: (Three Digits) 3. Name of Administrative Agency: Street Address: Mail Address: City: Email: 4. Type of Entity: Corporation Partnership Proprietorship Yes Yes JPA No No State: Zip: 5. Is the applicant a workers' compensation insurance carrier? 5. If yes, is the applicant a separate subsidiary to administer claims? 6. Name of Owner(s): 7. List the manager's name and adjusting location addresses and phone numbers below: 1ò Name of Manager: Administrative Agencyæ Street Address: City: Phone: Email: Two-digit SIP Adjusting Location Number Assigned to This Office: Form A4-50 (Rev 8/96) American LegalNet, Inc. www.FormsWorkFlow.com State: FAX: Zip: Page 2 7. (Continued) List the manager's name and adjusting location addresses and phone numbers below: 2ò Name of Manager: Administrative Agency: Street Address: Cityæ Phone: Email: Two-digit SIP Adjusting Location Number Assigned to This Office: 3ò Name of Manager: Administrative Agencyæ Street Address: City: Phone: Email: Two-digit SIP Adjusting Location Number Assigned to This Office: 4ò Name of Manager: Administrative Agency: Street Address: City: Phone: Email: Two-digit SIP Adjusting Location Number Assigned to This Office: 5ò Name of Manager: Administrative Agency: Street Address: Cityæ Phone: Email: Two-digit SIP Adjusting Location Number Assigned to This Office: State: FAX: Zipæ State: FAX: Zipæ State: FAX: Zipæ Stateæ FAX: Zipæ American LegalNet, Inc. www.FormsWorkFlow.com Page 3 7. (Continued) List the manager's name and adjusting location addresses and phone numbers below: 6ò Name of Manager: Administrative Agency: Street Address: City: Phoneæ Email: Two-digit SIP Adjusting Location Number Assigned to This Office: 7ò Name of Manager: Administrative Agency: Street Address: City: Phone: Email: Two-digit SIP Adjusting Location Number Assigned to This Office: 8. Name of Manager: Administrative Agency: Street Address: City: Phone: Email: Two-digit SIP Adjusting Location Number Assigned to This Office: 9ò Name of Manager: 2. Administrative Agency: Street Address: City: Phone: Email: Two-digit SIP Adjusting Location Number Assigned to This Office: State: FAX: Zipæ State: FAX: Zip: State: FAX: Zip: State: FAX: Zipæ American LegalNet, Inc. www.FormsWorkFlow.com Page 4 7. (Continued) List the manager's name and adjusting location addresses and phone numbers below: 10. Name of Manager: Administrative Agency: Street Address: City: Phone: Email: Two-digit SIP Adjusting Location Number Assigned to This Office: 8. List below the name of the city of each adjusting location in number 7 above; then the name of each self-insured employer serviced at that adjusting location; the number of the Certificate to Self Insure for each self-insured employer; and the name of the claims adjuster-who has demonstrated their individual competence by passing the Self Insurance Administrator's examination-who is responsible for the self insurer's claims at that adjusting location: Adjusting Location (City) Name of Self-insured Employer Certificate Number Name of Competent л®-±² State: FAX: Zip: American LegalNet, Inc. www.FormsWorkFlow.com Page 5 8. (Continued) Adjusting Location (City) Name of Self-insured Employer Certificate Number Name of Competant Person American LegalNet, Inc. www.FormsWorkFlow.com Page 6 9. Period of Time for Certificate Issuance Requestedæ 1 Year 2 Years 3 Years 10. Fees Due with this Application (not applicable to joint powers authorities and insurance carriers): øa) Base Fee $1000 for each Administrative Agency per year (includes initial adjusting location): $1000 x years = $ øb) Adjusting Location Fee of $200 for second and subsequent adjusting locations per year: $200 ¨ additional locations x years = $ (c) Fees Submitted with Application: $ The information submitted in this application is true and correct to the best of my knowledge. Signature of Person Completing Application: Typed Name of Person Completing Application: Title of Person Completing Application: Phone number: Date: American LegalNet, Inc. www.FormsWorkFlow.com