State of California Department of Industrial Relations OFFICE OF SELFINSURANCE PLANS APPLICATION FOR CERTIFICATE OF CONSENT TO SELFINSURE AS A PRIVATE EMPLOYER SELFINSURER All questions must be answered. If not applicable, enter 223N/A224. To the Director of the Department of Industrial Relations: The private employer identified below submits the following information to obtain a Certificate of Consent to SelfInsure the payment of workers222 compensation under California Labor Code Section 3700. NAME OF APPLICANT EMPLOYER: Address: City: State: Zip + 4: - Federal Tax ID # of Applicant: State of Incorporation: Date of Incorporation (mm-dd-yyyy): WHO SHOULD CORRESPONDENCE REGARDING THIS APPLICANT BE ADDRESSED TO: Name: Title: Company Name: Address: City: State: Zip + 4: - Phone: E-Mail: Does applicant currently have a California Certificate of Consent to SelfInsure? Yes No If yes, what is current Certificate Number: What is the desired effective date of selfinsurance if application is approve Will a policy applicant employer222s California workers222 compensation liability other than excess insurance be carried? Yes No If yes, what is the nature and scope of coverage? Describe the general nature of the business of the company: Form: A-1 (1-2016) | Page 1 American LegalNet, Inc. www.FormsWorkFlow.com Form: A-1 (1-2016) | Page 2 Yes No Applicants primary 3-digit NAICS Code: Is applicant or any subsidiaries in the professional employer (PEO) or staffing industries? Total number of applicant222s California employees: Will the number of California employers change more than 20% during the next 12 months? No Yes (If yes, briefly describe by how many and why): Complete the following for the California workers222 compensation policies for the most recent 3 years222 experience by policy period: Year Payroll Premium Before Dividend Losses Incurred Mod Factor $ $ $ $ $ $ $ $ $ Total For Past 3 Full Years: $ Name of current workers222 compensation carrier: Policy Number: Current Policy Termination Date: Is there any pending litigation or legal proceeding which might substantially adversely affect the business or financial condition of the Applicant: No Yes (If Yes, explain) SECURITY DEPOSIT Upon approval of this application, what form does the applicant anticipate posting its required deposit in? Cash Surety Bond Letter of Credit Approved Securities WORKPLACE SAFETY Please identify the person primarily responsible for applicant222s workplace safety and health programs: Name: Title: Phone: E-Mail: American LegalNet, Inc. www.FormsWorkFlow.com Form: A-1 (1-2016) | Page 3 LEGAL STRUCTURE TYPE OF ENTITY OWNERSHIP: Corporation Partnership Sole Proprietorship (Complete appropriate section below) CORPORATION Closely Held Publically Traded (Trading Symbol: , Exchange NYSE NASDAQ Other: State of Incorporation (if Corporation): Is the Applicant a wholly owned subsidiary of another firm? Yes No If yes, please identify Parent: PARTNERSHIP Name of all Partners and identify if they are general, special, limited, etc.: NAME ADDRESS TYPE SOLE PROPRIETORSHIP Owner222s Full Name: Address City State Zip +4 American LegalNet, Inc. www.FormsWorkFlow.com Form: A-1 (1-2016) | Page 4 CLAIMS ADMINISTRATION List the third party administrator the applicant proposes to use: Name: Title: Company Name: Address: City: State: Zip + 4: - Administrative Agency222s Certificate to Administer #: Will ALL claims be administered at the ONE adjusting location above? Yes No If N, and there will be multiple adjusting locations, identify additional locations below. Attach additional pages if necessary. Name: Title: Company Name: Address: City: State: Zip + 4: - Administrative Agency222s Certificate to Administer #: Name: Title: Company Name: Address: City: State: Zip + 4: - Administrative Agency222s Certificate to Administer #: American LegalNet, Inc. www.FormsWorkFlow.com Form: A-1 (1-2016) | Page 5 AGREEMENT I am acquainted with the affairs of the applicant to which representations made in the foregoing application and subsequent attachments and supporting documentation. I have read the application and attachments and believe them to be true to the best of my knowledge. X DATE: SIGNED: Authorized Representative Printed Name Title Telephone Number E-mail For questions or assistance in completing the application process, please feel free to initially call to discuss your application with one of OSIP222s Senior Compliance Officers at (916) 464-7000. American LegalNet, Inc. www.FormsWorkFlow.com Form: A-1 (1-2016) | Page 6 CHECK LIST FOR A COMPLETE SELFINSURED APPLICATION The California Code of Regulations, Title 8, Chapter 8, Subchapter 2, provides the requirements for submitting a complete SelfInsurer's Application. The following forms and documents are required by this section to be included with the application. In addition to a complete application (Form A-1), all of the following forms and attachments are required to complete the application. FILING FEE - $500.00: A check must accompany the application before processing will begin. Make checks payable to: Department of Industrial Relations-Office SelfInsurance Plans COMPLETE APPLICATION CHECKLIST: Form # Description A 226 1 Application A 226 4 Agreement and Assumption A 226 5 Resolution to SelfInsure A 226 5B Parental Guarantee (If requ ired) A 226 6 Agreement and Undertaking of Security Deposit 3 Years Audited Financial Statements Certificate of Status (see below) Filing Fee Check OTHER REQUIREMENTS: An original Certificate of Status or other appropriate license or registration documents showingthe applicant is licensed or registered to do business in California. SUBSIDIARY ENTITIES (IF NEEDED): For each additional subsidiary entity other than the primary master applicant that requires anindividual certificate issued in their name, complete Form A-3B for each and attach theappropriate fees. All combined fees may be paid by a single check. For questions or assistance in completing the application process, please feel free to initially call to discuss your application with one of OSIP222s Senior Compliance Officers at (916) 464-7000. American LegalNet, Inc. www.FormsWorkFlow.com