State of California Department of Industrial Relations OFFICE OF SELFINSURANCE PLANS GROUP AFFILIATE MEMBER INTERIM APPLICATION DATE: GROUP CERT. # GROUP NAME: AFFILIATE MEMBER (Legal Name): Principal California Address: City: State: Zip Phone TYPE OF ENTITY OWNERSHIP: Corporation Partnership Sole Proprietorship State of Incorporation (if Corporation): Federal Tax Identification Number of Group Member: Requested Effective Date of Interim Certificate: Nature of Business: 3-digit NAICS Code: OR 2-digit SIC Code: Current experience modification: Member222s annual California payroll during the last, or latest 12 month period: $ Period Reported: to . The Interim Certificate will be valid for 180 Days. The SelfInsured Group agrees to be financially responsible to pay all workers' compensation claim liabilities for the above Affiliate Group Member. X SIGNED: Group Authorized Representative Printed Name & Title Address City, State, Zip+4 Phone Form: S-2A (1-2016) American LegalNet, Inc. www.FormsWorkFlow.com