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Application For A Certificate Of Consent To Self Insure By A Group Of Employers Form. This is a California form and can be use in General Workers Comp.
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Tags: Application For A Certificate Of Consent To Self Insure By A Group Of Employers, A4-3, California Workers Comp, General
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.
GENERAL INFORMATION ON GROUP APPLICANT
GREETINGS:
1. 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
1. Name of Applicant Group:
the Honorable
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,
, one of the Justices of the
day of
, 20
2. Title:
(Attorney must sign above and type name below)
2. Company Name:
2. Mail Address:
2. City:
State:
2. Phone: (
)
FAX: (
Attorney(s) for Zip + 4:
)
Office and P.O. Address
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?
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
Form No. A4-3 (1/94)
No
If yes, enter Certificate Number:
Yes
No
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:
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
4. Reincorporation
4. Merger
-against4. Change in Identity
4. Majority Change in Ownership
4. New member additions to the Group
No
:No
No
No
:
No
Yes
Yes
Yes
Yes
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
(Continue on additional page if necessary.)
GREETINGS:
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
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.
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:
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)
Office and P.O. Address
No
Increased
or
Decreased
by how many?
Telephone No.:
Facsimile No.:
E-Mail Address:
Mobile Tel. No.:
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......... ..
:
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 testify and give evidence as a witness in this action on the part of the
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.
Witness, Honorable
Court in
County,
, one of the Justices of the
day of
, 20
(Attorney must sign above and type name below)
Attorney(s) for
Office and P.O. Address
NOTE: Certificates of Good Standing are available upon request and payment of a fee from:
California Secretary of State
1. Corporate Filing and Services Section No.:
Telephone
1500 11th Street Facsimile No.:
Sacramento, CA 95814
E-Mail Address:
(916) 653-2318
Mobile Tel.
2. Limited Partnerships Section: (916) 653-3365 No.:
3. Limited Liability Companies: (916) 653-3795
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:
Page 4
Index No.
9. (a) List Full Legal Name, check appropriate Business Status (i.e. Corporation, Partnership, Sole Proprietorship, Limited
9. (a) Liability Corporation or Limited Liability Partnership) and enter Federal Tax Calendar No.Number of ALL proposed
Identification
:
9. (a) member employers of this applicant group below (do not list DBAs or names of operating divisions):
Full Legal Name of MemberPlaintiff(s)
-against-
: Business Status *
JUDICIAL SUBPOENAID No.
Federal Tax
Corp Part SPro LLC LLP
:
1
2
:
3
:
4
Defendant(s)
:
......................................................
5
6
7
THE PEOPLE OF THE STATE OF NEW YORK
8 TO
9
10
GREETINGS:
11
WE COMMAND YOU, that all business and excuses being laid aside, you and each of you attend before
,
at the
Court
located at
13 County of
in room
, on the
day of
, 20
, at
o'clock in the
noon, and at any recessed
14 or adjourned date, to testify and give evidence as a witness in this action on the part of the
12 the Honorable
15
16
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
17
result of your failure to comply.
18
19
Witness, Honorable
Court in
County,
, one of the Justices of the
day of
, 20
20
21
(Attorney must sign above and type name below)
22
23
24
Attorney(s) for
25
26
Office and P.O. Address
27
28
29
30
Telephone No.:
Facsimile No.:
E-Mail Address:
Mobile Tel. No.:
* Corp = Corporation—Part = Partnership—SPro = Sole Proprietorship—LLC = Limited Liability Corporation—LLP = Limited Liability Partnership
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COURT
Full Legal Name of Member
Corp Part SPro LLC LLP
COUNTY .OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
31 . . . . . . . . . . .
:
Index No.
Federal Tax ID No.
Page 5
32
:
33
34
Plaintiff(s)
-against-
35
Calendar No.
:
JUDICIAL SUBPOENA
:
36
:
37
:
38
Defendant(s)
:
39 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
40
41 THE PEOPLE OF THE STATE OF NEW YORK
42
TO
43
44
45 GREETINGS:
WE COMMAND YOU, that all business and excuses being laid aside, you and each of you attend before
,
the Honorable
at the
Court
47 County of
located at
in room
, on the
day of
, 20
, at
o'clock in the
noon, and at any recessed
48
or adjourned date, to testify and give evidence as a witness in this action on the part of the
46
49
50
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
52 result of your failure to comply.
51
53
Witness, Honorable
County,
54 Court in
, one of the Justices of the
day of
, 20
55
56
(Attorney must sign above and type name below)
57
58
Attorney(s) for
59
60
61
Office and P.O. Address
62
63
64
65
Telephone No.:
Facsimile No.:
E-Mail Address:
Mobile Tel. No.:
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COURT
Full Legal Name of Member
Corp Part SPro LLC LLP
COUNTY .OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
66. . . . . . . . . . .
:
Index No.
Federal Tax ID No.
Page 6
67
:
68
69
Plaintiff(s)
-against-
70
Calendar No.
:
JUDICIAL SUBPOENA
:
71
:
72
:
73
Defendant(s)
:
74. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
75
76THE PEOPLE OF THE STATE OF NEW YORK
77
TO
78
79
80
GREETINGS:
WE COMMAND YOU, that all business and excuses being laid aside, you and each of you attend before
,
the Honorable
at the
Court
82County of
located at
in room
, on the
day of
, 20
, at
o'clock in the
noon, and at any recessed
83
or adjourned date, to testify and give evidence as a witness in this action on the part of the
81
84
85
Your failure to comply with this subpoena is punishable as a contempt of court and will make you liable to
86the party on whose behalf this subpoena was issued for a maximum penalty of $50 and all damages sustained as a
87result of your failure to comply.
88
89Court in
Witness, Honorable
County,
, one of the Justices of the
day of
, 20
90
91
(Attorney must sign above and type name below)
92
93
Attorney(s) for
94
95
96
Office and P.O. Address
97
98
99
100
Telephone No.:
Facsimile No.:
E-Mail Address:
Mobile Tel. No.:
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COURT
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......... ..
:
Page 7
Index No.
:
Calendar Certificate of Consent to Self
9. (b) Do any of the proposed members listed in Question 9 (a) above presently have an activeNo.
9. (b) Insure in California?
Yes
No Plaintiff(s)
:
JUDICIAL SUBPOENA
-against-
:
9. (b) If yes, identify each proposed member as listed in Question 9 (a) by line number and legal name and enter their current
9. (b) Certificate of Consent to Self Insure Number below:
Line No.
:
Legal Name of Member
Certificate Number
:
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 testify and give evidence as a witness in this action on the part of the
10. At the date of this application, is there any litigation or legalpunishable pending, or threatened, the result of which might
Your failure to comply with this subpoena is proceeding as a contempt of court and will make you liable to
10.the party on adversely affectthis financial condition, business a maximum of the group$50 and all damages sustained as a
substantially whose behalf the subpoena was issued for or operations penalty of applicant named in Question 1,
10.result of your failure to comply.
or any of its proposed members?
Yes
No
10. If Yes, explain:
Witness, Honorable
Court in
County,
, one of the Justices of the
day of
, 20
(Attorney must sign above and type name below)
Attorney(s) for
Office and P.O. Address
Telephone No.:
Facsimile No.:
E-Mail Address:
Mobile Tel. No.:
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:
Index No.
Page 8
:
Calendar No.
CONSOLIDATED FINANCIAL INFORMATION :ON APPLICANT GROUP
JUDICIAL SUBPOENA
Plaintiff(s)
-against11. Provide the following consolidated financial information for all members of the applicant group:
:
:
Current
20
or
1st Full Year
20
:
2nd Full Year
20
3rd Full Year
19
Quarters Defendant(s)
:
BALANCE.SHEET ITEMS:. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
....... ............
Liquid Assets
Inventory
Other Current Assets
THE PEOPLE OF THE STATE OF NEW YORK
Total Assets
Fixed Assets (Net)
TO
Other Assets
Total Assets
Current Liabilities
GREETINGS:
Long-term Debt
WE
Other Liabilities COMMAND YOU, that all business and excuses being laid aside, you and each of you attend before
,
the Honorable
at the
Court
Total Liabilities
located at
County of
Contributed Capital
in room
, on the
day of
, 20
, at
o'clock in the
noon, and at any recessed
Retained Earnings
or adjourned date, to testify and give evidence as a witness in this action on the part of the
Shareholders’ Equity
MISCELLANEOUS:
Working Capital failure to comply with this subpoena is punishable as a contempt of court and will make you liable to
Your
the party on
Gross Revenue whose behalf this subpoena was issued for a maximum penalty of $50 and all damages sustained as a
result of
Net Income your failure to comply.
(Before Fixed Charges*)
Witness, Honorable
Court in
County,
Net Profit
, one of the Justices of the
day of
, 20
*Fixed Charges = Taxes/Interest and Rental Charges
NOTE: Attach your published, independently prepared, audited financial report plus all notes and schedules for the past 3 full years,
NOTE: and quarterly financial reports for current year up through the most recent quarter.
(Attorney must sign above and type name below)
Attorney(s) for
Office and P.O. Address
Telephone No.:
Facsimile No.:
E-Mail Address:
Mobile Tel. No.:
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:
:
Page 9
Index No.
Calendar No.
WORKERS’ COMPENSATION EXPERIENCE IN CALIFORNIA
:
JUDICIAL SUBPOENA
Plaintiff(s)
12. (a) Complete the following consolidation of all members of the group applicant’s (named in Question 1) workers’
12. (a) compensation liabilities in-against- under the members’ various workers’ compensation insurance policies for the
California
:
12. (a) most recent three full calendar years:
Year
Payroll
Premium
Before Dividend
Experience
Modification
:
:
Losses
Incurred
Loss Ratio
Defendant(s)
:
......................................................
THE PEOPLE OF THE STATE OF NEW YORK
16. (b) Are any of the group members currently NOT covered by a workers’ compensation policy?
TO
Yes
No
16. (b)
16. (b) If yes, how many members?
Identify each below:
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 testify and give evidence as a witness in this action on the part of the
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.
Witness, Honorable
Court in
County,
, one of the Justices of the
day of
, 20
13. Will a policy covering any of the group applicant’s members’ California workers’ compensation liability,
(Attorney must sign above and type name below)
13. other than excess, be carried?
Yes
No
Attorney(s) for
17. If yes, what will be the nature and scope of this coverage?
Office and P.O. Address
Telephone No.:
Facsimile No.:
E-Mail Address:
Mobile Tel. No.:
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Index No.
Page 10
:
SECURITY DEPOSIT :
Plaintiff(s)
Calendar No.
JUDICIAL SUBPOENA
14. (a) If the group application is -against- the security deposit will be in the form of a:
approved,
:
19. (a)
19. (a)
19. (a)
19. (a)
19. (a)
Surety Bond
Letter of Credit
Approved Securities
Cash
Combination of above:
:
:
Defendant(s)
:
...
19. (b). . . . . . . . . . . . . if .you.wish .information .to . . .sent. to.you. on the.deposit selected in Question 14 (a)
Check here . . . . . . . . . . . . . . . be . . . . . . . . . . . .
—or you can download this information from our Web page at http://www.dir.ca.gov/sip
EMPLOYEE INJURY AND
THE PEOPLE OF THE STATE OF NEW YORKILLNESS PREVENTION PROGRAM
15. (a) Name of individual responsible for injury and illness prevention program for group applicant (named in Question 1): 20.
( TO
a
)
20. (a) Name:
Title:
20. (a) Address:
GREETINGS:
20. (a) City, State,COMMAND YOU, that all business and excuses being laid aside, you and each of you attend before
WE Zip + 4:
,
at the
Court
located at
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 inwitness in this action on the part of the
a this capacity with the group applicant?
20. (b) What percentage of this individual’s time is spent
the Honorable
20. (a) Phone: (
County of
)
If more than one individual is responsible for injury and illness prevention, attach a list to this application, giving the
information requested in Items (a) and (b) above.
Your failure to comply with this subpoena is punishable as a contempt of court and will make you liable to
the party on independent licensedsubpoena was issued for a safety professional, or certified industrial hygienist
20. (c) Name of whose behalf this California engineer, certified maximum penalty of $50 and all damages sustained as a
result of your failure to the injury
20. (a) who will be preparingcomply. and illness prevention program evaluation of the group applicant and preparing the
20. (c) written evaluation report on the members’ facilities in this group applicant:
Witness, Honorable
County,
20. (a) Name:
Court in
, one of the Justices of the
day of
Title:
, 20
20. (a) Company:
20. (a) Address:
(Attorney must sign above and type name below)
20. (a) City, State, Zip + 4:
20. (a) Phone: (
)
Attorney(s) for
Copy of Safety and Health Evaluation Report is attached.
Date of Report:
Office and P.O. Address
Evaluation and Report have been requested, and will be forwarded upon completion.
Telephone No.:
Facsimile No.:
E-Mail Address:
Mobile Tel. No.:
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:
Index No.
Page 11
:
Calendar No.
(Attach Injury and Illness Prevention Program Evaluation Report here.)
Plaintiff(s)
-against-
:
JUDICIAL SUBPOENA
:
:
:
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 testify and give evidence as a witness in this action on the part of the
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.
Witness, Honorable
Court in
County,
, one of the Justices of the
day of
, 20
(Attorney must sign above and type name below)
Attorney(s) for
Office and P.O. Address
Telephone No.:
Facsimile No.:
E-Mail Address:
NOTE: The member employer must abate all serious violations found at their facilities in the evaluation report.
Such abatement must be verified by the person Mobile Tel. No.:
conducting the evaluation.
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Index No.
Page 12
:
Calendar No.
PROPOSED CLAIMS ADMINISTRATION OF GROUP: SELFJUDICIAL SUBPOENA
INSURANCE PROGRAM
Plaintiff(s)
-against16. (a) 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 for applicant employer and preparation
16. (b) of the self insurers’ annual reports:
:
21. (a) Name (Person):
Title:
:
21. (b) Company:
Defendant(s)
:
......................................................
21. (b) Address:
21. (b) City, State, Zip + 4:
THE PEOPLE OF THE STATE OF NEW YORK
21. (b) Administrative Agency’s Certificate To Administer No.
TO
or
Admitted Workers’ Compensation Insurance Carrier Claim Department
16. (b) Has the individual administrator named above in Question 16 (a) demonstrated competence by passing the Self
20. (a) Insurance Administrator’s Test?
GREETINGS:
Yes
No
If yes, date:
WE COMMAND YOU, that all business and excuses being laid aside, you and each of you attend before
,
the Honorable of competent person who will do claimsat the has passed the Self Insurance Administrator’s Test:
Court
21. (b) If no, name
and who
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
21. (b) and date passed test:
17. Will ALL applicant group workers’ compensation claims be administered at the ONE adjusting location named in
17. Question Your failure to comply with this subpoena is punishable as a contempt of court and will make you liable to
16 (a)?
the party on whose behalf this subpoena was issued for a maximum penalty of $50 and all damages sustained as a
result of Yes failure to comply.complete the following information for each proposed adjusting location:
your
No
If no,
21. (a) Name Witness, Honorable
(Person):
Court in
21. (b) Company:
County,
Title:
day of
, one of the Justices of the
, 20
21. (b) Address:
(Attorney must sign above and type name below)
21. (b) City, State, Zip + 4:
21. (b) Administrative Agency’s Certificate To Administer No.
Attorney(s) for
or
Admitted Workers’ Compensation Insurance Carrier Claim Department
21. (b) Name (Person):
Title:
Office and P.O. Address
21. (b) Company:
21. (b) Address:
21. (b) City, State, Zip + 4:
21. (b) Administrative Agency’s Certificate To Administer No.
or
Telephone No.:
Facsimile No.:
E-Mail Address:
Mobile Tel. No.:
Admitted Workers’ Compensation Insurance Carrier Claim Department
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COURT
COUNTY .OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
......... ..
:
Index No.
Page 13
:
21. 21. (c) Name (Person):
Calendar No.
:
JUDICIAL SUBPOENA
Title:
Plaintiff(s)
221. 21.(d) Company:
-against-
:
21. 21. (d) Address:
:
21. 21. (d) City, State, Zip + 4:
:
21. 21. (d) Administrative Agency’s Certificate To Administer No.
Defendant(s)
:
. . . . . . . . . . or. . . . Admitted . . . . . . . . . . . . . . . . . . Insurance .Carrier Claim Department
.
. . . . . . . Workers’ Compensation . . . . . . . . . . . . .
21. 21. (d) Name (Person):
Title:
21. (b) THE PEOPLE OF THE STATE OF NEW YORK
Company:
21. (b) TO Address:
21. (b)
City, State, Zip + 4:
21. (b) GREETINGS:
Administrative Agency’s Certificate To Administer No.
or
Admitted YOU, that all business and excuses being laid aside, you
WE COMMAND Workers’ Compensation Insurance Carrier Claim Department and each of you attend before
,
the Honorable
at the
Court
located at
County of
(Add additional page if needed to list all location information.)
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
Your failure to comply with this subpoenaFILING FEESas a contempt of court and will make you liable to
GROUP is punishable
the party on whose behalf this subpoena was issued for a maximum penalty of $50 and all damages sustained as a
Attach youryour failurefor comply. of filing fees.
result of check here to payment
Make your check payable to: Department of Industrial Relations—Self Insurance Plans.
Filing Fee: Each group Honorable making application for a Certificate shall, at the time of of the such application,
Witness, of employers
, one filing Justices of the
Filing Fee: pay a non-refundable filing fee daythe following basis:
on of
Court in
County,
, 20
(1) A single application fee of $500.00 for the initial group self insurer filing.
(2) An application fee of $100.00 for each member of the group filing submitted together with the initial group filing.
(3) For any subsequent member application determined by the Manager to be necessarysign above and type name below)
(Attorney must but not submitted with the original
(3) group filing or for new member applications filed subsequently, the fee shall be an additional $500.00 for each additional
(3) member.
Attorney(s) for
Office and P.O. Address
Telephone No.:
Facsimile No.:
E-Mail Address:
Mobile Tel. No.:
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COURT
COUNTY .OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
......... ..
:
State of California
Department of Industrial Relations
Self Insurance Plans
:
Index No.
Calendar No.
:
AGREEMENT TO ABIDE BY SELF INSURANCE JUDICIAL SUBPOENA
REGULATIONS
Plaintiff(s)
-against-
:
:
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
Defendant(s)
:
. . . . . be. granted. or. continued .and .subject. to. the .full .right .and .authority .of the said Director of Industrial Rela. ..... . ....... .. .... . .. .. ... .. ...... .
tions to prescribe new and additional regulations. It is further agreed that, following revocation or invalidation of said certificate, the applicant will pay fees and expenses as provided in the regulations.
THE PEOPLE OF THE STATE OF NEW YORK
I,
,
(insert person’s name)
TO
(insert title of person)
certify under penalty of perjury, that I am acquainted with the affairs of said applicant employer to which
the representations and statements set forth in the foregoing application, attachments, exhibits and addenda
relate; that I have read said application, attachments, exhibits and addenda, know the contents thereof and
GREETINGS:
that said representations and statements therein contained are true to the best of my knowledge, information, and belief.
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
Subscribed and sealed at
,
(State)
in room
, on the (City)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
this
day of
, 20
.
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
Signature
result of your failure to comply.
Witness, Honorable
SEAL
Court in
County,
Title
day of
, one of the Justices of the
, 20
(Attorney must sign above and type name below)
Attest:
Attorney(s) for
Office and P.O. Address
Signature of Secretary
(Typed Name and Title of Secretary)
Telephone No.:
Facsimile No.:
E-Mail Address:
Mobile Tel. No.:
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COURT
COUNTY .OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
......... ..
:
:
Index No.
Calendar No.
:
RESOLUTIONS AND AGREEMENTS
JUDICIAL
Plaintiff(s)
SUBPOENA
Each group applicant must adopt -againstand execute—as part of the application—two Board of Directors Resolutions and several
:
agreements, which are outlined below:
:
1. RESOLUTION BY APPLICANT GROUP TO BECOME SELF INSURED
:
The first Resolution is a resolution to become self insured for workers’ compensation liabilities. The resolution is adopted by
the Board of Directors of the group applicant corporation named in Question 1. The group applicant will need to identify
Defendant(s)
several positions in the resolution by position title that are authorized to sign the application and other Self Insurance docu:
. . . . . . . . . . . . . . . . . . . . . . . . . . . . applicant. . . . . . . . . . . . .
ments and agreements. on behalf of. the.group . . . . . . . . This .includes. the .Resolution to become self insured. Position titles
might include Chairman of the Board of Directors, Member of Board of Directors, President, any Vice President, Secretary,
Treasurer, Risk Manager. DO NOT USE the names of the current incumbents to the positions.
The resolution mustOF THEoriginal “wet” NEW YORK authorized person and the “wet” signature of the Corporate
THE PEOPLE have an STATE OF signature of the
Secretary. You will need to emboss the corporate seal on the resolution.
TO
2. RESOLUTION OF GROUP ASSUMPTION AND GUARANTEE OF MEMBER LIABILITIES
The second Resolution is a resolution by the applicant group to assume and guarantee the workers’ compensation liabilities of
each group member granted an Affiliate Certificate of Consent to Self Insure by the Director of Industrial Relations as part of
the applicant group. The resolution is adopted by the Board of Directors of the group applicant corporation named in QuesGREETINGS:
tion 1. The group applicant will need to identify several positions in the resolution by position title that are authorized to sign
the Agreement of Assumption and Guarantee for the members as well as to sign the corporate resolution on behalf of the
WE COMMAND YOU, that all business and excuses being laid aside, you and each of you attend before
group applicant. Position titles might include Chairman of the Board of Directors, Member of Board of Directors, President,
,
the Honorable Secretary, Treasurer, Risk Manager. DOat the USE the names of the current incumbents to the positions.
Court
any Vice President,
NOT
located at
County of
The resolution must have an original “wet” signature of the authorized person and the “wet” signature of the Corporate
in room
, to the
, 20
, at
o'clock in the
noon, and at any recessed
Secretary. You will need onemboss the day of seal on the resolution.
corporate
or adjourned date, to testify and give evidence as a witness in this action on the part of the
Future additions to the group will be added by addendum to the initial Resolution or by execution of a new Resolution.
3. AGREEMENT OF ASSUMPTION AND GUARANTEE FOR GROUP MEMBERS
Having adopted thefailure toAssumption and Guarantee Resolution (see item 2 above), the of court and will make you liable to
Your enabling comply with this subpoena is punishable as a contempt group applicant must also execute
thethe party on whose Assumption and Guarantee ofissued forCompensation Liabilities (Form and all damages sustained as a
actual Agreement of behalf this subpoena was Workers’ a maximum penalty of $50 A4-3G) for the initial group
members.of your failure to comply.
result A single Agreement of Assumption is executed that includes an Attachment listing each initial member of the
group. Future additions to the group will be added by a new Assumption Agreement Form listing the new member(s).
Witness, Honorable
, one
4. AGREEMENT AND UNDERTAKING FOR SECURITY DEPOSIT BY GROUP of the Justices of the
Court in
County,
day of
, 20
The third agreement to be signed is an agreement that the Applicant Group will post a security deposit to secure its group
workers’ compensation self insurance program and that the State may use the deposit and any interest earned to pay compensation due if the group defaults.
This agreement must also be executed by one of the persons identified in (Attorney must sign above and type name below) title
the Group Corporate Resolution by position
that is authorized to sign documents on behalf of the Applicant Group. Like the resolution, the agreement must have an
original “wet” signature of the authorized person and of the Corporate Secretary. You will need to emboss the corporate seal
in the box as indicated on the agreement page.
Attorney(s) for
5. AGREEMENT AND RESOLUTION OF JOINT AND SEVERAL LIABILITY
Each initial MEMBER of the group applicant and all future additions to the group shall execute an Agreement of Joint and
Several Liability for any and all workers’ compensation liabilities of the applicant group. This is part of the Member portion
of the Group Application. If the member is a corporation, it must also execute a Resolution Address Several Liability by
Office and P.O. of Joint and
its Board of Directors. Partnerships (non-corporate) and individual proprietorships need only execute the Agreement of Joint
and Several Liability.
Telephone No.:
Facsimile No.:
THE TWO GROUP RESOLUTIONS AND THE THREE GROUP AGREEMENTS FOLLOW IN THE ORDER
LISTED ABOVE. COMPLETE EACH ONE AND SUBMIT WITH E-Mail Address:
THE GROUP APPLICATION.
Mobile Tel. No.:
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COURT
COUNTY .OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
......... ..
:
State of California
Department of Industrial Relations
Self Insurance Plans
:
Form GR-1 (1/94)
Index No.
Calendar No.
:
JUDICIAL
Plaintiff(s)
GROUP RESOLUTION AUTHORIZING APPLICATION TO SUBPOENA
THE DIRECTOR OF INDUSTRIAL RELATIONS,: STATE OF CALIFORNIA
-againstFOR A CERTIFICATE OF CONSENT TO SELF INSURE WORKERS’ COMPENSATION LIABILITIES
:
At a meeting of the Board of Trustees of
:
,
Defendant(s)
:
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . (enter .name . . applicant’s .group.corporation)
. . . . . . . of . . . . . . . . . . . . .
a corporation organized and existing under the laws of the State of
,
held on the
day of
THE PEOPLE OF THE STATE OF NEW YORK
20
,
a quorum being present, the following Resolution was adopted:
TO
RESOLVED that the
GREETINGS:
(enter titles of authorized corporate officers)
WE COMMAND YOU, that all business and excuses being laid aside, you and each of Consent to before
be and they are hereby severally authorized and empowered to make application for a Certificate of you attendSelf
,
the Honorable
at the
Court
located Relations of the State of California, and to execute any and all documents
County of to the Department of Industrial at
Insure
in room
, on the
day of
, 20
, at
o'clock in the
noon, and at any recessed
required for such application, including the Agreement and in this action Security Deposit,
or adjourned date, to testify and give evidence as a witness Undertaking foron the part of theand Agreement to Abide
by Self Insurance Regulations.
Your failure to comply with this subpoena is punishable as a contempt of court and will make you liable to
I,
, the undersigned
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.
Secretary of the said
, a corporation,
Witness, Honorable
hereby certify that I am the Secretary of said corporation, that the foregoing is , one of the Justices of theof the
a full, true and correct copy
Court in
County,
day of
, 20
resolution duly passed by the Board of Trustees 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
(Attorney must sign above and type name below)
and effect.
Attorney(s) for
IN WITNESS WHEREOF: I HAVE HEREUNTO SET MY HAND AND THE CORPORATE SEAL OF
SAID CORPORATION THIS
DAY OF
20
.
Office and P.O. Address
(SEAL)
Telephone No.:
Facsimile No.:
Secretary
E-Mail Address:
Mobile Tel. No.:
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COURT
COUNTY .OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
......... ..
:
State of California
Department of Industrial Relations
Self Insurance Plans
Index No.
:
:
Form GR-2 (1/94)
Plaintiff(s)
Calendar No.
JUDICIAL SUBPOENA
RESOLUTION OF AGREEMENT OF ASSUMPTION AND GUARANTEE
:
OF WORKERS’-againstCOMPENSATION LIABILITIES FOR A GROUP SELF INSURER
:
At a meeting of the Board of Directors of
:
,
Defendant(s)
:
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . (name . . group . . . insurer) .
. . . . of . . . . self . . . . .
a corporation organized and existing under the laws of the State of
,
held on the
day of
THE PEOPLE OF THE STATE OF NEW YORK
20
,
a quorum being present, the following Resolution was adopted:
TO
RESOLVED that
,
(name of group self insurer)
GREETINGS: under the laws of the State of
organized
,
WE COMMAND YOU, that all business and excuses being laid aside, you and each of you attend before
authorizes that
,
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
(list legal name & state of incorporation of group self insurer)
Your failure to comply with this subpoena is punishable as a contempt of court and will make you liable to
seeks Certificate of Consent to Self Insure workers’ maximum penalty of in and all of California; and,
the party ona whose behalf this subpoena was issued for a compensation liabilities$50 the Statedamages sustained as a
result of your failure to comply.
BE IT FURTHER RESOLVED that
Witness, Honorable
Court in
County,
(name of group self insurer)
day of
, one of the Justices of the
, 20
will guarantee the payment of all workers’ compensation liabilities incurred by any member of said group issued an
Affiliate Certificate of Consent to Self Insure workers’ compensation liabilities in the State of California or resulting
(Attorney must sign above and type name below)
from operations of such members of said group self insurer in California as a permissibly self insured; and
Attorney(s) for
BE IT FURTHER RESOLVED that the Chairman of the Board of Trustees, (Board Member, or Group
Administrator) of
Office and P.O. Address
(name of group self insurer)
are severally authorized to sign the State of California form entitled Agreement of Assumption and Guarantee of
Telephone No.:
Workers’ Compensation Liabilities on behalf of the members of Facsimileself insurer and be bound by all terms and
the group No.:
E-Mail Address:
conditions therein, including, but not limited to, terms specifying assumption of all member liability; and
Mobile Tel. No.:
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COURT
COUNTY .OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
......... ..
:
Index No.
:
Plaintiff(s)
BE IT FURTHER RESOLVED that
-against-
Calendar No.
:
JUDICIAL SUBPOENA
:
(name of group self insurer)
will guarantee the payment of all workers’ compensation liabilities :incurred by any additional member of said
:
group, not named in the initial Agreement of Assumption and Guarantee of workers’ compensation liabilities, that in
Defendant(s)
:
. . . . .the .future should .be .granted .an .Affiliate. Certificate of Consent .to . . Insure workers’ compensation liabilities as
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Self
part of said group self insurer in the State of California, and the Secretary of
THE PEOPLE OF THE STATE OF NEW YORK
(name of group self insurer)
TO is authorized to add the additional members’ name as an attachment to this resolution and said Secretary shall
re-execute the resolution with said attachment and provide it to the Department of Industrial Relations (or its
successor).
GREETINGS:
WE COMMAND YOU, that all business and excuses being laid aside, you and each of you attend before
,
the Honorable
at the
Court
I,
, the undersigned
located at
County of
in room
,
day of
, 20
, at
o'clock in the
noon, ,and at any recessed
Secretary of theon the
a corporation,
or adjourned date, to testify and give evidence as a witness in this action on the part of the
(name of group self insurer)
hereby certify that I am the Secretary of said corporation, that the foregoing is a full, true and correct copy of
Your failure passed by with this subpoena thereof at a meeting of said Board held and will make you
the resolution dulyto comply the Board of Directorsis punishable as a contempt of court on the day and at the liable to
the party on whose behalf this subpoena was issued for a maximum penalty of $50 and all damages sustained as a
result place therein specified, and that said resolution has never been revoked, rescinded, or set aside, and is now in full
of your failure to comply.
forceWitness, Honorable
and effect.
Court in
County,
, one of the Justices of the
day of
, 20
IN WITNESS WHEREOF: I HAVE HEREUNTO SET MY HAND AND THE CORPORATE SEAL OF
(Attorney must sign above and type name below)
SAID CORPORATION THIS
DAY OF
20
.
Attorney(s) for
(SEAL)
Secretary
Office and P.O. Address
Telephone No.:
Facsimile No.:
E-Mail of the holding corporation can choose any
NOTE: The officers authorized by job title in this resolution are examples. The BoardAddress:
Mobile Tel. No.:
NOTE: officer by designated job title to act on its behalf with respect to the Self Insurance Plans’ program of the members.
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COURT
COUNTY .OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
......... ..
Form A 4-3G (1/94)
:
Index No.
:
:
Plaintiff(s)
-against-
Calendar No.
JUDICIAL SUBPOENA
State of California :
Department of Industrial Relations
:
SELF INSURANCE PLANS
:
Defendant(s)
:
In . . . Matter of the.Application.of. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
the . . . . . . . . . . . . . . . . . .
THE PEOPLE OF THE STATE OF NEW YORK
AGREEMENT OF ASSUMPTION
AND GUARANTEE OF
WORKERS’ COMPENSATION LIABILITIES
FOR GROUP MEMBERS
TO
Group Self Insurer,
WHEREAS,
GREETINGS:
Insurer), has good and sufficient reason for executing this Agreement; and
(hereinafter called the Undersigned Group Self
WE COMMAND YOU, that all business and excuses being laid aside, you and each of you attend before
WHEREAS, the member employers named in Attachment 1 (hereinafter collectively and individually called
,
the Honorable
at the
Court
Affiliate Self Insurer), is, or has made application to be, a self insurer pursuant to Sections 3700 et seq. of the Labor Code of
located at
County of
California;
in room
, on the
day of
, 20
, at
o'clock in the
noon, and at any recessed
or adjournedTHEREFORE, It is understood and agreed that: in this action on the part of the
date, to testify and give evidence as a witness
NOW,
1. In consideration of the Director of Industrial Relations of the State of California issuing an Affiliate Certificate of
Consent to Self Insure to said Affiliate Self Insurer, the Undersigned Group Self Insurer agrees to assume and guarantee to
Your failure to comply with this subpoena is punishable as a contempt of court and will make you liable to
pay, or otherwise discharge promptly, all the liabilities and obligations which said Affiliate Self Insurer may incur as a self
the party California workers’this subpoenaliabilities. for a maximum penalty of $50 and all damages sustained as a
on whose behalf compensation was issued
insurer of its
result of your failure to comply.
2. This Agreement shall cover and extend to all potential liability of workers’ compensation benefits as required by
law of said Affiliate SelfHonorable a self insurer of its California workers’ compensation liabilities arising onof the the
Witness, Insurer; as
, one of the Justices or after
effective date hereof as a member of the Undersigned Group Self 20
Insurer.
Court in
County,
day of
,
3. This Agreement shall not cover or extend to any workers’ compensation liabilities of said Affiliate Self Insurer
which are expressly insured by a carrier duly authorized to write California workers’ compensation insurance.
(Attorney must sign above and type name below)
4. This Agreement shall remain in full force and effect unless terminated in the manner hereinafter provided.
5. This Agreement may be terminated at any time by the Undersigned Group Self Insurer upon giving thirty (30)
Attorney(s) for
days written notice by overnight courier, registered or certified mail to the Manager, Self Insurance Plans. In this event the
liability of the Undersigned Group Self Insurer shall, at the expiration of thirty (30) days from receipt of said written notice
by said Manager, cease and determine, except as to such liability of the Affiliate Self Insurer on account of any injury
suffered by any of its employees prior to the expiration of said thirty (30) days; it being expressly understood and agreed that
the Undersigned Group Self Insurer shall be liable for default of said Affiliate Self Insurer in fully discharging all existing
Office and P.O. Address
and potential liability of said Affiliate Self Insurer as a self insurer as of the date of said termination.
6. A change in the proprietorship or the sale of said Affiliate Self Insurer does not terminate this Agreement.
Telephone No.:
7. In the event said Affiliate Self Insurer shall fail to pay compensation, as compensation is defined in Section 3207,
Facsimile No.:
Labor Code of California, when due, the Undersigned Group Self InsurerE-Mail Address: and the payment may be
will pay the same,
enforced against the Undersigned Group Self Insurer to the same extent as if said payment was the liability of it.
Mobile Tel. No.:
(Continued on next page)
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COUNTY .OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
......... ..
:
Index No.
:
:
Plaintiff(s)
-against-
Calendar No.
JUDICIAL SUBPOENA
:
:
8. The Undersigned Group Self Insurer is held and firmly bound for the payment of all legal costs incurred by the
:
State of California in any actions taken to enforce this Agreement.
Defendant(s)
:
. . . . . 9..If . . . Undersigned.Group.Self. Insurer.has .not . . . . with.the .California Secretary of State to the extent required to
. . the . . . . . . . . . . . . . . . . . . . . . . . . filed . . . . . . . .
entitle it to transact intrastate business in California, it hereby agrees to submit itself to the jurisdiction of the Department of
Industrial Relations, the Division of Workers’ Compensation and the California courts for the purpose of enforcing the
liabilities and obligations arising from this Agreement.
THE PEOPLE OF THE STATE OF NEW YORK
10. If the Undersigned Group Self Insurer has not filed with the California Secretary of State to the extent required
to entitle it to transact intrastate business in California, it hereby agrees that service of process may be effected on the
TO
Undersigned Group Self Insurer by sending notice to
by overnight courier, registered mail or certified mail. Pursuant to California Code of Civil Procedure Section 415.40, service
of GREETINGS: of mail will be deemed complete on the tenth day after such mailing.
notice by this form
WE COMMAND be binding all business and excuses being laid aside, you and each assigns.
11. This Agreement shallYOU, that upon the Undersigned Group Self Insurer, its successors, and of you attend before
,
the Honorable
at the
Court
located at
County of
12. Attachment 1 lists the member self insurers of the Undersigned Group Self Insurer.
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
Your failure to comply with this subpoena is punishable as a contempt of court and will make you liable to
Subscribed and sealed at behalf this subpoena was issued for a maximum penalty of $50 and all damages sustained as a
the party on whose
result of your failure to comply.
this
day of
Witness, Honorable
Court in
County,
, 20
.
, one of the Justices of the
Attest:
day of
, 20
(Attorney must sign above and type name below)
CORPORATE SEAL
Name of Group Self Insurer
Attorney(s) for
Signature of Authorized Officer
Secretary
Title
Office and P.O. Address
Telephone No.:
Facsimile No.:
E-Mail Address:
Mobile Tel. No.:
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COUNTY .OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
.. ...
Form A 4-8 .(1/94). . . . .
:
Index No.
:
Plaintiff(s)
-against-
Calendar No.
:
JUDICIAL SUBPOENA
State of California :
Department of Industrial Relations
:
SELF INSURANCE PLANS
:
Defendant(s)
:
.. .... . .. ....... .
In the .Matter. of. the .Certificate .of . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
INDEMNITY AGREEMENT
AND POWER OF ATTORNEY
THE PEOPLE OF THE STATE OF NEW YORK
TO
A Group Self Insurer,
WHEREAS,
,
GREETINGS:
hereafter referred to as the “Group Member,” is making or has made application to the Director of Industrial Relations for an
Affiliate Certificate of Consent to YOU, that pursuant to California Labor Code laid aside, you and each of you attend before
WE COMMAND Self Insure all business and excuses being Sections 3700 through 3705 as a member
self insurer of a group of employers; and
,
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
WHEREAS, a group of employers have organized and formed a non-profit mutual benefit corporation known as
,
hereafter referred to as the “Group Self Insurer,” for the sole purpose of being a workers’ compensation group self insurer
Your failure to comply with this subpoena is punishable as a contempt of court and will make you liable to
pursuant to California Labor Code Section 3700; and
the party on whose behalf this subpoena was issued for a maximum penalty of $50 and all damages sustained as a
result of the failure to comply.
WHEREAS,youraforementioned Group Self Insurer is making or has made application to the Director of Industrial Relations
for a Certificate of Consent to Self Insure pursuant to California Labor Code Sections 3700 through 3705 as a group self
insurer for a group of employers; and
Witness, Honorable
, one of the Justices of the
Court in
County,
day of
, 20
WHEREAS, the Group Members of said Group Self Insurer have designated a Board of Trustees consisting of
members or
(Attorney must sign above and type name below)
Attorney(s) the
to direct the affairs of said Group Self Insurer and to select or terminate membership infor Group Self Insurer, subject to the
approval of the Director of Industrial Relations as set forth in California Labor Code Sections 3700 through 3705; and
WHEREAS, the Group Members and the Group Self Insurer understand and agree that the issuance of a Certificate of
Consent to Self Insure to the Group Self Insurer and the issuance of an Affiliate Certificate of Consent to Self Insure to each
Office and P.O. Address
Group Member is subject to the following conditions, to wit:
I. The Group Self Insurer and each of its Group Members are jointly and severally liable for paying and securing liabilities of
the Group Self Insurer and its Group Members for the payment of any and all compensation liability required by Labor Code
Telephone No.:
Sections 3700 through 3705 of any and all employees of any Group Member of the Group Self Insurer and/or of the Group
Facsimile No.:
Self Insurer itself, provided the compensation liability results from an occurrence with a date of injury during the period of
E-Mail Address:
membership in said Group Self Insurer; and
Mobile Tel. No.:
(Continued on next page)
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COUNTY .OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
......... ..
:
Index No.
II. The Group Self Insurer shall have authority to enforce this Indemnity Agreement against each and every one of its Group
Members or former Group Members. In the event of a failure of the Group Self Insurer to enforce the rights of indemnity as
:
Calendar No.
set forth herein, and after reasonable notice to the Group Self Insurer or any Group Member or former Group Member by the
Director, or his/her duly appointed agents, the Director of Industrial Relations shall have the independent right to enforce the
:
JUDICIAL SUBPOENA
Plaintiff(s)
terms of this Indemnity Agreement against any and all of the Group Members or former Group Members for the payment of
all compensation liabilities, and all liabilities of the Group Members for any:delinquent contribution and/or assessments; and
-againstIII. The Board of Trustees of the Group Self Insurer shall designate and appoint a Group Administrator empowered to accept
:
service of process on behalf of the Group Self Insurer itself and for any of its Group Members or former Group Members.
Said Group Administrator shall be authorized to act on behalf of the Group Self Insurer and its Group Members in all
:
transactions relating to or arising out of the operation of the Group Self Insurer. Said Group Administrator shall have responsibility and authority for the maintenance of an effective injury and illness prevention program for the Group Self Insurer and
Defendant(s)
:
all .Group.Members, .the posting. of.security. deposit .to .secure .all. liabilities. of. the Group Self Insurer, the employment of legal
.... ....... ....... . ..... ..... . .... . ...... .
counsel, accountants, actuaries, claims administration services, and any other services deemed necessary. Said Group
Administrator shall also have the authority to contract for specific excess and/or aggregate excess insurance coverage for the
Group Self Insurer and all Group Members. The Group Administrator shall have the authority to bind the Group Self Insurer
and all Group MembersTHE STATE OF NEW YORK
THE PEOPLE OF jointly and severally; and
IV.TO change in the identity of the Group Administrator shall be immediately communicated to the Manager of the Office
Any
of Self Insurance Plans. In the absence of a duly appointed Group Administrator, any Trustee of the Board of Trustees of the
Group Self Insurer shall be authorized to accept service of process on behalf of the Group Self Insurer itself, and of all Group
Members; and
V. GREETINGS: the duly appointed Group Administrator and/or the Board of Trustees of said Group Self Insurer fails to
In the event that
maintain the financial solvency of the Group Self Insurer, or defaults on the payment of compensation liabilities due from the
WE COMMAND YOU, that all business and excuses the compensation you and each Group attend before
Group Self Insurer, or fails to post the required security deposit to secure being laid aside, liabilities of the of you Self
,
the Honorable
at the
Court
Insurer, the Director of Industrial Relations shall have the authority to appoint a Conservator to act in place of the Group
located at
County of
Administrator; and
in room
, on the
day of
, 20
, at
o'clock in the
noon, and at any recessed
VI. The Group Administrator shall actgive evidence as a witness in this action on the part of the the Group Self Insurer
or adjourned date, to testify and as the true and lawful attorney-in-fact for the use and benefit of
and its Group Members and shall have the power to:
Ask, demand, sue for, recover, collect and receive all such sums of money due, debts, interest, dividends, and any demands
whatsoever as are or shall hereafter become due, owing, payable to the Group Self Insurer and court andMembers, and shall
Your failure to comply with this subpoena is punishable as a contempt of its Group will make you liable to
have the use and whose behalf this subpoena the name of the Group Self Insurer and its Group Members for recovery
the party on take lawful ways and means in was issued for a maximum penalty of $50 and all damages sustained as a
thereof, and your failure toand agree for the same and other sufficient discharges for the Giving and Granting unto said
result of to compromise comply.
Group Administrator attorney-in-fact full power and authority to do and perform every act necessary, requisite or proper to be
done as a Group Self Insurer and/or its Group Members could lawfully do, with full power of substitution and revocation,
Witness, Honorable
, one of the cause to be done
hereby ratifying and confirming all that the Group Administrator attorney-in-fact shall lawfully do orJustices of the by
Court in
County,
day of
, 20
virtue hereof.
Executed at
this
,
(Attorney must sign above and type name below)
day of
, 20
by
Attorney(s) for
* Signature:
Typed Name & Title:
Office and P.O. Address
Company Name:
(* notarize signature)
Telephone No.:
Facsimile No.:
E-Mail Address:
Mobile Tel. No.:
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COUNTY .OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
......... ..
:
State of California
Department of Industrial Relations
Self Insurance Plans
Index No.
:
Form A 4-GAU (1/94)
:
Plaintiff(s)
-against-
Calendar No.
JUDICIAL SUBPOENA
:
:
In the Matter of the Application of
:
AGREEMENT AND
UNDERTAKING FOR
SECURITY DEPOSIT
Defendant(s)
:
......................................................
Group Self Insurer, OF a Certificate of Consent to YORK
THE PEOPLE for THE STATE OF NEW Self Insure
The
TO undersigned employer, if it elects to self insure in accordance with the provisions of Sections 3700-3705 of the
Labor Code of California, and having made application for or received from the Director of Industrial Relations of the State
of California a Certificate of Consent to Self Insure, upon furnishing proof satisfactory to the Director of Industrial Relations
of ability to self insure and to compensate any or all of its affiliate self insurers’ employees for injury or disability, and their
dependents for death incurred or sustained by said employees, pursuant to the terms, provisions and limitations of said Labor
GREETINGS:
Code, does hereby undertake and agree, as a condition to issuance of such Certificate of Consent to Self Insure and in
consideration of the issuance thereof by the Director of Industrial Relations, as follows:
WE COMMAND YOU, that all business and excuses being laid aside, you and each of you attend before
,
the HonorableSelf Insurer will make a security deposit with the State of California, to secure incurred liability
at the
Court
1. The Group
located at
County the payment of compensation as provided in said Labor Code such security deposit as may, by the
of
1. for
in1. order of the Director theIndustrial Relations, be required to be, filed.
room
, on of
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. Said security deposit shall be held by the State of California to the order of said Director of Industrial
2. Relations, in trust, with power to the said Director to collect or order the collection of the principal or the
2. interest, or both, as the same becomes or become due; to sell or order the sale of such security deposit and
2. any security failure to comply therefor, orsubpoenathereof, or both,as a contempt of any compensation
Your deposit substituted with this such part is punishable to the payment court and will make you liable to
2. for which application of the proceeds or the interest, or for a maximum penalty of $50 and all damages
the party on whose behalf this subpoena was issued both, to the payment of any compensation for which sustained as a
2. said your Self Insurer may become liable under said Labor Code, in the payment of which said Group Self
result ofGroup failure to comply.
2. Insurer or any Affiliate Self Insurer may be in default. The interest upon security deposit posted hereunder
2. shall be remitted to the employer, upon request, by the State of California as it matures in the absence of
Witness, Honorable
, one may become liable
2. default of said employer in the payment of any compensation for which said employer of the Justices of the
Court in said Labor Code.
County,
day of
, 20
2. under
(Attorney must sign above and type name below)
Signed at
this
day of
, 20
.
Attorney(s) for
Attest:
Signature
(
Office and P.O. Address
Title
SEAL
Telephone No.:
Facsimile No.:
E-Mail Address:
Mobile Tel. No.:
By
Secretary
Title
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COURT
COUNTY .OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
......... ..
:
Index No.
ATTACHMENT 1
to the Agreement of Assumption and Guarantee of Workers’ Compensation Liabilities for Group Members
:
Calendar No.
for
Plaintiff(s)
(Name of Group)
-againstThe member employers of the above named group are:
JUDICIAL SUBPOENA
:
:
Legal Name
1
:
Federal Tax ID Number
:
Defendant(s)
:
......................................................
2
3
4
THE PEOPLE OF THE STATE OF NEW YORK
5 TO
6
7
GREETINGS:
8
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
10
in room
, on the
day of
, 20
, at
o'clock in the
noon, and at any recessed
11 or adjourned date, to testify and give evidence as a witness in this action on the part of the
9 the Honorable
12
13
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
14
result of your failure to comply.
15
16
Witness, Honorable
Court in
County,
, one of the Justices of the
day of
, 20
17
18
(Attorney must sign above and type name below)
19
20
21
Attorney(s) for
22
23
Office and P.O. Address
24
25
Telephone No.:
Facsimile No.:
E-Mail Address:
Mobile Tel. No.:
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COURT
COUNTY .OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
......... ..
:
ATTACHMENT 1
(Continued)
Plaintiff(s)
(Name of Group)
-againstThe member employers of the above named group are:
:
Calendar No.
:
JUDICIAL SUBPOENA
:
:
Legal Name
26
Index No.
Federal Tax ID Number
:
Defendant(s)
:
....................................
