Form: S-2B (1-2016) State of California Department of Industrial Relations OFFICE OF SELFINSURANCE PLANS APPLICATION FOR AFFILIATE CERTIFICATE OF CONSENT TO SELFINSURE AS A MEMBER OF A GROUP SELFINSURER All questions must be answered. If not applicable, enter 223N/A224. To the Director of the Department of Industrial Relations: The employer identified below submits the following information to obtain an Affiliate Certificate of Consent to SelfInsure as a member of a group selfinsurer to secure the payment of workers222 compensation under California Labor Code Section 3700. NAME OF APPLICANT EMPLOYER: IF A PARTNERSHIP, LLC OR LLP (Name all partners and designate whether they are general, special, limited, etc.): Name Address Designation Does the applicant have any corporate subsidiaries (if so, subsidiary must file own application)? Yes No Subsidiary Name Address Operation Does the applicant currently have a California Certificate of Consent to SelfInsure? Yes No If yes, what is the current Certificate Number? Number of Affiliate222s California employees to be covered by this selfinsurance plan: Will the number of California employees covered under the proposed selfinsurance plan materially change in the next 12 months? Yes No If yes, by how many Increase Decrease American LegalNet, Inc. www.FormsWorkFlow.com Indicate net profit or loss after taxes for the last 3 years. Year Amount 20 $ 20 $ 20 $ Name of current carrier Current policy termination date Complete the following for the applicant222s California workers222 compensation policies for the most recent 3 years222 experience by policy period (include most recent partial year through last quarter): Year Payroll Premium Before Dividend Experience Modification Losses Incurred Loss Ratio Will a policy covering any of the applicant employer222s California workers222 compensation liability other than excess insurance be carried? Yes No If yes, what will be the nature and scope of this coverage? Name of individual responsible for workplace injury and illness prevention program: Name Title Address Telephone Number REQUIRED ATTACHMENTS: Groups Affiliate Member Interim Application Form S-2A (if not previously submitted).Executed Resolution to be SelfInsured as a Member of Group SelfInsurer Form S-3.Executed Indemnity Agreement Form S-4. I certify under penalty of perjury that I am acquainted with the affairs of the said applicant employer to which representations made in the foregoing application, that I have read the application and attachments, know the contents thereof and that said representations and statements contained therein are true to the best of my knowledge, information and belief. X SIGNED: Group Authorized Representative Printed Name & Title American LegalNet, Inc. www.FormsWorkFlow.com