STATE OF CALIFORNIA Department of Industrial Relations Division of Workers' Compensation Administrative Director Post Office Box 420603 San Francisco, CA 94142-0603 Telephone: (510) 286-7100 Petition for Permission to Negotiate a Section 3201.7 Labor-Management Agreement Labor Code § 3201.7; Title 8, California Code of Regulations § 10202 Please submit the following information to the Administrative Director of the Division of Workers' Compensation to obtain a letter advising the below-named union and employer, or group of employers, of their eligibility to enter into negotiations for the purpose of reaching agreement on a labor-management agreement authorized by Section 3201.7 of the California Labor Code. (Print or Type Name and Addresses) 1. Union Information Name of Union: ________________________________________________________________ Contact Person and Title: _________________________________________________________ Principal Address: ______________________________________________________________ 2. Employer Information (For group of employers, please use separate pages to list all individual employers.) Name of Employer: _____________________________________________________________ Contact Person and Title: _________________________________________________________ Federal Employers Identification Number (FEIN): _____________________________________ Principal Business of Employer: ___________________________________________________ Principal Address: ______________________________________________________________ 3. Please describe the bargaining unit or units to be covered by the Section 3201.7 labormanagement agreement, and provide the approximate number of employees in the unit(s). 4. Please attach proof of the union's status as the exclusive bargaining representative of the employees in the above-described bargaining unit(s). 5. Please attach a copy of the current collective bargaining agreement or agreements in effect between the union and the employer. 1 DWC Form RGS-1 (012004) American LegalNet, Inc. www.USCourtForms.com I declare under penalty of perjury under the laws of the State of California that the foregoing is true and correct. EXECUTED AT _________________ (City), CALIFORNIA ON _____________(Date) BY: ___________________________________________, TITLE: _______________________ (Original Signature of Union Representative) You must attach a proof of service by mail declaration indicating that the petition and all supporting evidence was mailed to the employer, or for a group of employers, all individual employers. 2 DWC Form RGS-1 (012004) American LegalNet, Inc. www.USCourtForms.com