Application For Self Insurance Administrators Examination
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Application For Self Insurance Administrators Examination Form. This is a California form and can be use in General Workers Comp.
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Tags: Application For Self Insurance Administrators Examination, A 4-100, California Workers Comp, General
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
APPLICATION FOR
SELF INSURANCE ADMINISTRATOR’S EXAMINATION
The undersigned person hereby applies to take the Self Insurance Administrator’s Examination:
Please Print
1. Name of Applicant:
1. Home Address:
Apt. No.:
2. City:
1. Daytime Phone: (
State:
Zip:
)
2. Mail confirmation of examination and test results to the following address (if different from above):
2. Name:
2. Company Name:
2. Street Address:
Suite:
2. City:
State:
Zip:
3. Identification Information on Applicant:
5. Driver’s License No.:
Issuing State:
2. Social Security Number:
2. Pursuant to the Federal Privacy Act of 1974 you are hereby notified that it is a mandatory requirement to
2. provide your Social Security Number. This information will only be used by the Office of Self Insurance Plans
2. for identification purposes.
4. Testing Location Requested:
Northern California
Southern California
5. Attach application fee in the amount of $100.00. Make check or money order payable to Self Insurance Plans.
6. (Do not send cash.) Application fee is not refundable after Self Insurance Plans issues its confirmation of your
6. application, seating you in the examination. Checks returned for insufficient funds will automatically result in
6. rejection of your application and substitution of another candidate into your seat for the examination.
6. Incomplete applications will not be accepted.
Date:
19
Original Signature of Applicant
Form No. A4-100 (12/97)
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