State of California Department of Industrial Relations OFFICE OF SELFINSURANCE PLANS GROUP MASTER APPLICATION FOR CERTIFICATE OF CONSENT TO SELFINSURE AS A GROUP SELFINSURER All questions must be answered. If not applicable, enter 223N/A224. To the Director of the Department of Industrial Relations: The private group identified below submits the following information to obtain a Certificate of Consent to SelfInsure for itself an Affiliate certificates for each group member to secure the payment of workers222 compensation under California Labor Code Section 3700. NAME OF APPLICANT GROUP: Address: City: State: Zip + 4: - Federal Tax ID # of Group: State of Incorporation: Date of Incorporation (mm-dd-yyyy): (Note: Group Self-Insurer must be a California corporation as required by CCR 24715470.) WHO SHOULD CORRESPONDENCE REGARDING THIS GROUP BE ADDRESSED TO: Name: Title: Company Name: Address: City: State: Zip + 4: - Phone: E-Mail: What is the commencement date of the Group? Upon Approval by Director Other date: Does the applicant Group currently have a California Certificate of Consent to SelfInsure? Yes No If yes, what is the current Certificate Number: Total Number of Affiliate222s California employees to be covered by Group: Will a policy covering any of applicant employer222s California workers222 compensation liability other than excess insurance be carried? Yes No Form: S-1 (1-2016) | Page 1 American LegalNet, Inc. www.FormsWorkFlow.com Form: S-1 (1-2016) | Page 2 If yes, what is the nature and scope of coverage? Complete the following for the combined Affiliate222s California workers222 compensation policies for the most recent 3 years222 experience by policy period: Year Payroll Premium Before Dividend Losses Incurred $ $ $ $ $ $ $ $ $ Total For Past 3 Full Years: $ What is the primary 3-digit NAICS Code for the members of the Group: Describe the nature of the business(es) the Affiliate members engage in: Is there any pending litigation or legal proceeding which might substantially adversely affect the business or financial condition of the Group Applicant: No Yes (If Yes, explain) How many initial Group Affiliate member(s) will there be upon approval of this application? (Note: Completed applications (Forms S-2A & S-2B) must be submitted for each initial affiliate member with this Group application, or prior to issuance of the Certificate of Consent to SelfInsure for the Group.) Upon approval of this application, what form does the Group anticipate posting its required deposit in? Cash Surety Bond Letter of Credit Approved Securities I am acquainted with the affairs of the applicant Group to which representations made in the foregoing application. I have read the application and attachments and believe them to be true to the best of my knowledge. X DATE: SIGNED: Group Authorized Representative Printed Name & Title American LegalNet, Inc. www.FormsWorkFlow.com Form: S-1 (1-2016) | Page 3 CLAIMS ADMINISTRATION List the third party administrator the Group proposes to use: Name: Title: Company Name: Address: City: State: Zip + 4: - Administrative Agency222s Certificate to Administer #: Will ALL Group claims be administered at the ONE adjusting location above Yes No If NO, 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: S-1 (1-2016) | Page 4 CHECK LIST FOR A COMPLETE SELFINSURED GROUP APPLICATION The California Code of Regulations, Title 8, Chapter 8, Subchapter 2, Article 2, provides the requirements for submitting a complete Group SelfInsurer's Application and Group Affiliate Member's Application. The following forms and documents are required by this section to be included with the application. All required information must be submitted with the application formGroup SelfInsurer Requirements: The group is a California non-profit, mutual benefit corporation formed for the sole purpose ofoperating a group workers' compensation selfinsurance fund to pool compensation liabilities oftwo or more private employers.All group members have the same predominant, first 3-digit North American IndustryClassification System Code (NAICS Code). Group Application Forms and Fees: Completed Group application (Form S-1 (1-2016)) for the group's non-profit mutual benefitcorporation. Certificate of Status in good standing for Group Corporation from Secretary of State. Completed application form(s) from all proposed initial Affiliate members (Form S-2A & S-2B) withattachments. Filing fee of $1000 for group applicant. Filing fee for each member filed with this group application is $500. Feasibility Study: A copy of the Initial Feasibility Study as required in Section 15471 of these regulations. The feasibility study must include the following: The advantages and disadvantages of group selfinsurance for the proposed group members ascompared to the options of individual selfinsurance, or coverage under a policy issued by a carrier(s).Identification of all proposed group members and the combined total payroll for the proposed group selfinsurer.A consolidated summary of the historical workers' compensation claims loss experience and theallocated loss expenses of the proposed group members for the three most recent, completed, full policyyears, as well as the current partially completed policy year to the most current quarter under the currentpolicy.A five year proforma financial statement including, as a minimum, an income statement, balance sheet,projected cash flows, and claims payout projections. The proforma financial statement must include adetailed separation of assets, liabilities, retained earnings, taxes and dividends. If any claims costs arediscounted, the interest rate assumptions and payout patterns must be described and based onreasonable assumptions.A summary of the specific details of the group selfinsurer's operating plan, including but not limited to: a.The legal and organizational structure. American LegalNet, Inc. www.FormsWorkFlow.com Form: S-1 (1-2016) | Page 5 Method of governance.General management of the pool, including underwriting policies, insurance coverage, billing.Rating plans or premiums or other means by which group funding during the first five years ofoperation will be generated, and the amounts to be generated by the methods proposed for each of thefirst 5 years of operation.The first 12 month budget of the group selfinsurer.Excess insurance coverage including estimated cost, attachment point of specific excess coveragepolicy and aggregate excess policy (if any), and maximum liability of each excess policy.Summary of the third party claims administration agency chosen to handle the group selfinsurer'sclaims.Safety and loss control services that will be available from the group selfinsurer to group members.Underwriting requirements for initial and subsequent member selection into the group selfinsurer,including particular emphasis as to whether any underwriting requirement would be excluded fromcoverage by the specific excess or aggregate excess insurance coverage.Name of certified public accountant that will prepare annual financial reports for the group selfinsurer.Name of actuary and their professional actuarial designation who will prepare actuarial reports for thegroup selfinsurer and the frequency of such evaluation reports.Means by which the group selfinsurer will post the required security deposit.Any fidelity coverage and errors and omissions coverage that will be maintained by the group selfinsurer and the frequency of such evaluation reports. Assumption and Guarantee: An Agreement of Assumption and Guarantee of Liabilities of Workers' Compensation Liabilitiesfor Group Members (Form S-5 (1-2016)) executed by the group applicant, as required in Section15203.1 of these regulations. Resolution: Resolution by the Board of Trustees (Form S-3 (1-2016)) of the Group applican