Request For Interim Certificate
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Request For Interim Certificate Form. This is a California form and can be use in General Workers Comp.
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Tags: Request For Interim Certificate, California Workers Comp, General
State of California
Department of Industrial Relations
REQUEST FOR INTERIM CERTFICATE
To: Mark B. Ashcraft, Manager
Office of Self Insurance Plans
2265 Watt Avenue, Suite 1
Sacramento, CA 95825
Date:
Dear Mr. Ashcraft:
Re: Request for Interim Certificate
Please consider this request for issuance of an Interim Certificate for the following subsidiary or affiliate of our company,
,
which holds Certificate of Consent to Self Insure No.
:
1. Legal Name of Subsidiary/Affiliate:
2. State of Incorporation of Subsidiary/Affiliate:
3. Federal Tax Identification Number of Subsidiary/Affiliate:
4. Requested Effective Date of Interim Certificate:
5. Annual California Payroll of Subsidiary during the last 12 months or the latest 12-month period that payroll figures are available:
$
Period reported:
to
If the Interim Certificate above is granted, on behalf of the Master Certificateholder named above, I hereby bind our company
to be financially responsible to pay all workers’ compensation claim liabilities arising out of the period of time the Interim
Certificate is granted.
Please forward the application forms to this office for completion. I am aware the Interim Certificate will remain in effect for
180 days and the application process must be completed within this time period.
Sincerely,
(Signature)
Typed Name:
Title:
Company Name:
Street Address:
City:
Phone: (
State:
)
Zip + 4:
Fax: (
)
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