Form A-1 "Application for Certificate of Consent to Self-insure as a Private Employer Self-insurer" - California

What Is Form A-1?

This is a legal form that was released by the California Department of Industrial Relations - a government authority operating within California. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on January 1, 2016;
  • The latest edition provided by the California Department of Industrial Relations;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of Form A-1 by clicking the link below or browse more documents and templates provided by the California Department of Industrial Relations.

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Form: A-1 (1-2016) | Page 1
State of California
Department of Industrial Relations
Clear
Save
Print
Office of Self-Insurance Plans
11050 Olson Drive, Suite 230
Rancho Cordova, Ca. 95670
Phone (916) 464-7000
Fax (916) 464-7007
State of California
Department of Industrial Relations
OFFICE OF SELF-INSURANCE PLANS
APPLICATION FOR CERTIFICATE OF CONSENT
TO SELF-INSURE AS A PRIVATE EMPLOYER SELF-INSURER
All questions must be answered. If not applicable, enter “N/A”.
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 Self-Insure the payment of workers’
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 Self-Insure?
Yes
No
If yes, what is the current Certificate Number: ___________
What is the desired effective date of self-insurance if the application is approved___________________
Will a policy covering any of applicant employer’s California workers’ 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
State of California
Department of Industrial Relations
Clear
Save
Print
Office of Self-Insurance Plans
11050 Olson Drive, Suite 230
Rancho Cordova, Ca. 95670
Phone (916) 464-7000
Fax (916) 464-7007
State of California
Department of Industrial Relations
OFFICE OF SELF-INSURANCE PLANS
APPLICATION FOR CERTIFICATE OF CONSENT
TO SELF-INSURE AS A PRIVATE EMPLOYER SELF-INSURER
All questions must be answered. If not applicable, enter “N/A”.
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 Self-Insure the payment of workers’
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 Self-Insure?
Yes
No
If yes, what is the current Certificate Number: ___________
What is the desired effective date of self-insurance if the application is approved___________________
Will a policy covering any of applicant employer’s California workers’ 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 2
Applicants primary 3-digit NAICS Code: _____________
Is applicant or any subsidiaries in the professional employer (PEO) or staffing industries?
Yes
No
Total number of applicant’s 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 workers’ compensation policies for the most recent 3 years’
experience by policy period:
Year
Payroll
Premium Before Dividend
Losses Incurred
Mod Factor
$
$
$
$
$
$
$
$
$
0
$
Total For Past 3 Full Years:
Name of current workers’ 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 applicant’s workplace safety and health programs:
Name: ________________________________________ Title: _______________________________
Phone: _____________________________ E-Mail: _________________________________________
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 the Parent:
__________________________________________________________
PARTNERSHIP
Name of all Partners and identify if they are general, special, limited, etc.:
TYPE
ADDRESS
NAME
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
SOLE PROPRIETORSHIP
Owner’s Full Name: __________________________________________________________________
Address ___________________________________________________________________________
City __________________________________________State ________ Zip +4 __________________
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 Agency’s Certificate to Administer #: ___ ___ ___
Will ALL 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 Agency’s Certificate to Administer #: ___ ___ ___
Name: _____________________________________ Title: _______________________________
Company Name: _________________________________________________________________
Address: ________________________________________________________________________
City: ________________________________ State: __________ Zip + 4: __________ - _________
Administrative Agency’s Certificate to Administer #: ___ ___ ___
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 OSIP’s Senior Compliance Officers at (916) 464-7000.