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 Our File: APPLICATION FOR A CERTIFICATE OF CONSENT TO ADMINISTER WORKERS’ COMPENSATION SELF INSURANCE CLAIMS INSTRUCTIONS: 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.: 3. Name of Administrative Agency: 3. Street Address: 3. Mail Address: 3. City: State: Zip: 4. Type of Entity: Corporation Partnership Proprietorship JPA 5. Is the applicant a workers’ compensation insurance carrier? Yes No 5. If yes, is the applicant a separate subsidiary to administer claims? Yes No 6. Name of Owner(s): 7. List the manager’s name and adjusting location addresses and phone numbers below: 1. Name of Manager: 1. Administrative Agency: 1. Street Address: 1. City: 1. Phone: ( State: ) FAX: ( Zip: ) 1. Two-digit SIP Adjusting Location Number Assigned to This Office: Form A4-50 (Rev 8/96) 2001 © American LegalNet, Inc. Page 2 7. (Continued) List the manager’s name and adjusting location addresses and phone numbers below: 2. Name of Manager: 2. Administrative Agency: 2. Street Address: 2. City: 2. Phone: ( State: ) FAX: ( Zip: ) 2. Two-digit SIP Adjusting Location Number Assigned to This Office: 3. Name of Manager: 2. Administrative Agency: 2. Street Address: 2. City: 2. Phone: ( State: ) FAX: ( Zip: ) 2. Two-digit SIP Adjusting Location Number Assigned to This Office: 4. Name of Manager: 2. Administrative Agency: 2. Street Address: 2. City: 2. Phone: ( State: ) FAX: ( Zip: ) 2. Two-digit SIP Adjusting Location Number Assigned to This Office: 5. Name of Manager: 2. Administrative Agency: 2. Street Address: 2. City: 2. Phone: ( State: ) FAX: ( Zip: ) 2. Two-digit SIP Adjusting Location Number Assigned to This Office: 2001 © American LegalNet, Inc. Page 3 7. (Continued) List the manager’s name and adjusting location addresses and phone numbers below: 6. Name of Manager: 2. Administrative Agency: 2. Street Address: 2. City: 2. Phone: ( State: ) FAX: ( Zip: ) 2. Two-digit SIP Adjusting Location Number Assigned to This Office: 7. Name of Manager: 2. Administrative Agency: 2. Street Address: 2. City: 2. Phone: ( State: ) FAX: ( Zip: ) 2. Two-digit SIP Adjusting Location Number Assigned to This Office: 8. Name of Manager: 2. Administrative Agency: 2. Street Address: 2. City: 2. Phone: ( State: ) FAX: ( Zip: ) 2. Two-digit SIP Adjusting Location Number Assigned to This Office: 9. Name of Manager: 2. Administrative Agency: 2. Street Address: 2. City: 2. Phone: ( State: ) FAX: ( Zip: ) 2. Two-digit SIP Adjusting Location Number Assigned to This Office: 2001 © American LegalNet, Inc. Page 4 7. (Continued) List the manager’s name and adjusting location addresses and phone numbers below: 10. Name of Manager: 10. Administrative Agency: 10. Street Address: 10. City: 10. Phone: ( State: ) FAX: ( Zip: ) 10. 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-insured8. 8. employer serviced at that adjusting location; the number of the Certificate to Self Insure for each self-insured 8. employer; and the name of the claims adjuster—who has demonstrated their individual competence by passing the 8. 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 Person 2001 © American LegalNet, Inc. Page 5 8. (Continued) Adjusting Location (City) Name of Self-insured Employer Certificate Number Name of Competent Person 2001 © American LegalNet, Inc. Page 6 9. Period of Time for Certificate Issuance Requested: 1 Year 2 Years 3 Years 10. Fees Due with this Application (not applicable to joint powers authorities and insurance carriers): 10. (a) Base Fee $650 for each Administrative Agency per year (includes initial adjusting location): $650 x years = $ 10. (b) Adjusting Location Fee of $100 for second and subsequent adjusting locations per year: $100 x additional locations x years = $ 10. (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: 2001 © American LegalNet, Inc.