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 Yes No 4. (a) State of Incorporation (b) PARTNERSHIP Yes No (b) Name and Designation of Partners 4. (a) Date of Incorporation Month Day Year 4. 4. (c) Sole Proprietor Yes No (d) Limited Liability Corporation Yes No Form No. A4-5 (11/97) 2001 © American LegalNet, Inc. 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: Year Payroll Premium Before Dividend Experience Modification Losses Incurred 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): Title: 21. (b) Name of Agency/Carrier/Company: 21. (b) Address: 21. (b) City, State, Zip + 4: 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, , the undersigned Secretary of the said , 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 Relations 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. I, , , (Insert person’s name) (Insert person’s title) 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 that said representations and statements therein contained are true to the best of my knowledge, information, and belief. Subscribed and sealed at , (City) this day of (State) , 19 . (Signature) (Title) Attest: (Signature of Secretary) ( (Type name and title of Secretary) (APPLY CORPORATE SEAL OF (APPLICANT IN THIS BOX) NOTE: The agreement must be signed by one of the persons authorized by title in the resolution on the previous page. NOTE: As such, both name and title must be provided. The attesting person cannot also be the person signing the agreement. NOTE: The seal needs to be affixed in the box provided. 2001 © American LegalNet, Inc. Form A 4-3 (6/96) State of California Department of Industrial Relations SELF INSURANCE PLANS Certificate Number: In the Matter of the Certificate of AGREEMENT OF ASSUMPTION AND GUARANTEE OF WORKERS’ COMPENSATION LIABILITIES Employer, WHEREAS, and sufficient reason for executing this Agreement; and (hereinafter called the Undersigned), has good WHEREAS, (hereinafter called Self Insurer), is, or has made application to be, a self insurer pursuant to Sections 3700 through 3705 inclusive of the Labor Code of California; NOW, THEREFORE, It is understood and agreed that: 1. In consideration of the Director of Industrial Relations of the State of California issuing a Certificate of Consent to Self Insure to said Self Insurer, the Undersigned agrees to assume and guarantee to pay, or otherwise discharge promptly, all the liabilities and obligations which said Self Insurer may incur as a self insurer of its California workers’ compensation liabilities. 2. This Agreement shall cover and extend to all potential liability for workers’ compensation benefits as required by law of said Self Insurer; as a self insurer of its California workers’ compensation liabilities arising on or after the effective date thereof. 3. This Agreement shall not cover or extend to any workers’ compensation liabilities of said Self Insurer which are expressly insured by a carrier duly authorized to write California workers’ compensation insurance. 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 upon giving thirty (30) days written notice by registered or certified mail to the Manager, Self Insurance Plans. In this event the liability of the Undersigned, shall, at the expiration of thirty (30) days from receipt of said notice by said Manager cease and determine, except as to such liability of the 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 shall be liable for default of said Self Insurer in fully discharging all existing and potential liability of said Self Insurer as a self insurer as of the date of said termination. 6. A change in the proprietorship or the sale of said Self Insurer does not terminate this Agreement. 7. In the event said Self Insurer shall fail to pay compensation, as compensation is defined in Section 3207, Labor Code of California, when due, the Undersigned will pay the same, and the payment may be enforced against the Undersigned to the same extent as if said payment was the liability of it. (Continued on next page) 2001 © American LegalNet, Inc. 8. The Undersigned 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. 9. If the Undersigned has not filed with the California Secretary of State to the extent required to entitle it to transact intrastate business in California and/or if the Undersigned is a foreign entity (an entity organized and existing under the laws of a country outside the United States of America) it hereby agrees to become subject to the jurisdiction of the Department of Industrial Relations, the Division of Workers’ Compensation, all other administrative agencies, and become controlled by California law including all regulations promulgated by the Director of Industrial Relations for the administration of self insurance for the purpose of enforcing the liabilities and obligations, and the resolution of any dispute arising from this Agreement. 10. If the Undersigned 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 Undersigned by sending notice to by registered airmail, return-receipt requested. Pursuant to California Code of Civil Procedure Section 415.40, service of notice by this form of mail will be deemed complete on the tenth day after such mailing. 11. This Agreement shall be binding upon the Undersigned, its successors, and assigns. IF A CORPORATION: Subscribed and sealed at this day of , 19 . Attest: CORPORATE SEAL Company Signature Secretary Title 2001 © American LegalNet, Inc. Model Assumption and Guarantee Corporate Resolution RESOLUTION OF AGREEMENT OF PARENTAL ASSUMPTION AND GUARANTEE At a meeting of the Board of Directors of , (name of holding 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 , (name of holding corporation) organized under the laws of the State of , authorizes that its legally controlled subsidiary(ies) or affiliate(s) (list legal name & state of incorporation of each subsidiary or affiliate) seek a Certificate of Consent to Self Insure workers’ compensation liabilities in the State of California; and, BE IT FURTHER RESOLVED that (name of holding corporation) will guarantee the payment of all workers’ compensation liabilities incurred by any self-insured subsidiary or affiliate named above, resulting from operations in California as a permissibly self insured; and BE IT FURTHER RESOLVED that the President, any Vice President, Treasurer and Secretary of the (name of holding corporation) are severally authorized to sign the State of California form entitled Agreement of Assumption and Guarantee of Workers’ Compensation Liabilities on behalf of the subsidiary(ies) or affiliate(s) and be bound by all terms and conditions therein, including, but not limited to, terms specifying assumption of all subsidiary(ies) and affiliate(s) liability; and 2001 © American LegalNet, Inc. BE IT FURTHER RESOLVED that (name of holding corporation) will guarantee the payment of all workers’ compensation liabilities incurred by any additional self-insured subsidiary or affiliate, not named above, that in the future should be granted a Certificate of Consent to Self Insure workers’ compensation liabilities in the State of California, and the Secretary of (name of holding corporation) is authorized to add the subsidiary or affiliate 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). I, , the undersigned Secretary of the , a corporation, (name of holding corporation) hereby certify that I am the said 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 NOTE: The officers authorized by job title in this model resolution are examples. The Board of the holding corporation can choose NOTE: any officer by designated job title to act on its behalf with respect to the Self Insurance Plans’ program of the NOTE: subsidiary(ies). 2001 © American LegalNet, Inc.