State of California Department of Industrial Relations OFFICE OF SELFINSURANCE PLANS PRIVATE INTERIM APPLICATION ssuance of a DATE: CERT. # MASTER CERTIFICATE HOLDER NAME: (Legal Name): Principal California Address: City: State: Zip Phone Requested Effective Date of Interim Certificate: The Interim Certificate will be valid for 180 Days. The SelfInsured Employer agrees to be financially responsible to pay all workers' compensation claim liabilities for the above . X SIGNED: Employer Authorized Representative Printed Name & Title Address City, State, Zip+4 Phone Form: A-3A (1-2016) American LegalNet, Inc. www.FormsWorkFlow.com