Form A-2 "Application for Certificate of Consent to Self-insure as a Public Agency Employer Self-insurer" - California

What Is Form A-2?

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-2 by clicking the link below or browse more documents and templates provided by the California Department of Industrial Relations.

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Download Form A-2 "Application for Certificate of Consent to Self-insure as a Public Agency Employer Self-insurer" - California

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Form: A-2 (1-2016) | Page 1
State of California
Department of Industrial Relations
Clear
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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 PUBLIC AGENCY EMPLOYER SELF-INSURER
All questions must be answered. If not applicable, enter “N/A”.
To the Director of the Department of Industrial Relations: The public agency 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.
LEGAL NAME OF APPLICANT (Show exactly as on Charter or other official documents):
___________________________________________________________________________________
Address: ___________________________________________________________________________
City: ___________________________________ State: __________ Zip + 4: __________ - _________
Federal Tax ID # of Group: ____________________
CONTACT - Who Should Correspondence Regarding This Applicant Be Addressed To:
Name: ________________________________________ Title: _______________________________
Company Name: ____________________________________________________________________
Address: ___________________________________________________________________________
City: ___________________________________ State: __________ Zip + 4: __________ - _________
Phone: _____________________________ E-Mail: _________________________________________
TYPE OF PUBLIC ENTITY (Check one):
City and/or County
School District
Police and/or Fire District
Hospital District
Joint Powers Authority
Other (describe): __________________________________________
TYPE OF APPLICATION (Check one):
New Application
Reapplication (Merger/Unification)
Reapplication (Name Change)
Other (describe): _________________________________________________________________
Date Self-Insurance Program will begin: ___________________________________________________
Form: A-2 (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 PUBLIC AGENCY EMPLOYER SELF-INSURER
All questions must be answered. If not applicable, enter “N/A”.
To the Director of the Department of Industrial Relations: The public agency 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.
LEGAL NAME OF APPLICANT (Show exactly as on Charter or other official documents):
___________________________________________________________________________________
Address: ___________________________________________________________________________
City: ___________________________________ State: __________ Zip + 4: __________ - _________
Federal Tax ID # of Group: ____________________
CONTACT - Who Should Correspondence Regarding This Applicant Be Addressed To:
Name: ________________________________________ Title: _______________________________
Company Name: ____________________________________________________________________
Address: ___________________________________________________________________________
City: ___________________________________ State: __________ Zip + 4: __________ - _________
Phone: _____________________________ E-Mail: _________________________________________
TYPE OF PUBLIC ENTITY (Check one):
City and/or County
School District
Police and/or Fire District
Hospital District
Joint Powers Authority
Other (describe): __________________________________________
TYPE OF APPLICATION (Check one):
New Application
Reapplication (Merger/Unification)
Reapplication (Name Change)
Other (describe): _________________________________________________________________
Date Self-Insurance Program will begin: ___________________________________________________
Form: A-2 (1-2016) | Page 2
_________________________________________________________________________________________________________
______________
______CURRENT WORKERS’ COMPENSATION PROGRAM__________
___
______
Currently Insured with State Fund Policy # ___________________ Expiration Date: ____________
Currently Self Insured, Certificate # ____________________
Other (describe): _________________________________________________________________
_________________________________________________________________________________________________________
______________
_____CLAIMS ADMINISTRATION
__________
___
______
Who will be administering your agency’s workers’ compensation claims? (Check one)
JPA will administer
Third Party Administrator, TPA Certificate # _________________
Public entity will self-administer
Insurance Carrier will administer
Name of Third Party Administrator:
Name: _____________________________________ Title: _______________________________
Company Name: _________________________________________________________________
Address: ________________________________________________________________________
City: ________________________________ State: __________ Zip + 4: __________ - _________
Phone: _____________________________ E-Mail: ______________________________________
# of claims reporting locations to be used to handle Agency’s claims: ________
Does applicant currently have a California Certificate of Consent to Self-Insure?
Yes
No
If yes, what is the current Certificate Number: ___________
Total Number of Affiliate’s California employees to be covered by Group: _____________________
_________________________________________________________________________________________________________
______________
_____AGENCY EMPLOYER
__________
___
______
Current # of Agency Employees: _________ # of Public Safety Employees (police//fire): _________
If school District, # of certificated employees: _________
Will all Agency employees be covered by this self-insurance plan?
Yes
No
If ‘No’, explain who is not covered and how workers’ compensation coverage will be provided to the
excluded employees:
________________________________________________________________________________
Form: A-2 (1-2016) | Page 3
_________________________________________________________________________________________________________
______________
_____JOINT POWERS AUTHORITY
__________
___
______
Will applicant be a member of a JPA for workers’ compensation ?
Yes
No (If ‘yes’, complete the following)
Effective date of JPA Membership: ____________________ JPA Certificate # _____________________
Name of JPA: ________________________________________________________________________
_________________________________________________________________________________________________________
______________
_ _____AGENCY SAFETY PROGRAM
__________
___
______
Does the Agency have a written Injury and Illness Prevention Program (IIPP)?
Yes
No
Individual responsible for Agency workplace safety and IIPP program:
Name: _____________________________________ Title: _______________________________
Company Name: _________________________________________________________________
Address: ________________________________________________________________________
City: ________________________________ State: __________ Zip + 4: __________ - _________
Phone: _____________________________ E-Mail: ______________________________________
_________________________________________________________________________________________________________
______________
_ _____SUPPLEMENTAL COVERAGE
__________
___
______
1.) Will your program be supplemented by any insurance or pooled coverage under a STANDARD
workers’ compensation insurance policy?
Yes
No (If ‘Yes’, complete the following):
Name of Excess Pool/Carrier: ___________________________________________________________
Policy #: _________________________ Effective Date of Coverage: ____________________________
2.) Will your program be supplemented by any insurance or pooled coverage under a SPECIFIC
EXCESS workers’ compensation insurance policy?
Yes
No (If ‘Yes’, complete the following):
Name of Excess Pool/Carrier: ___________________________________________________________
Policy #: _________________________ Effective Date of Coverage: ____________________________
Retention Limits: _____________________________________________________________________
3.) Will your program be supplemented by any insurance or pooled coverage under an AGGREGATE
EXCESS (stop loss) specific excess workers’ compensation insurance policy?
Yes
No
(If ‘Yes’, complete the following):
Name of Excess Pool/Carrier: ___________________________________________________________
Policy #: _________________________ Effective Date of Coverage: ____________________________
Retention Limits: _____________________________________________________________________
Form: A-2 (1-2016) | Page 4
_________________________________________________________________________________________________________
______________
____RESOLUTION FROM GOVERNING BOARD
________
___
______
Attach a properly executed Governing Board Resolution. See attached sample resolution on page 5.
_________________________________________________________________________________________________________
______________
_ ___
__CERTIFICATION
__________
___
______
The undersigned on behalf of the applicant hereby applies for a Certificate of
Consent to Self-Insure the payment of workers' compensation liabilities pursuant
to Labor Code Section 3700. The above information is submitted for the purpose
of procuring said Certificate from the Director of Industrial Relations, State of
California. If the Certificate is issued, the applicant agrees to comply with
applicable California statutes and regulations pertaining to the payment of
compensation that may become due to the applicant's employees covered by the
Certificate.
X_____________________________________________
DATE: __________________________________
SIGNED: Authorized Official / Representative
______________________________________________
Printed Name
______________________________________________
Title
______________________________________________
Agency Name
Form: A-2 (1-2016) | Page 5
RESOLUTION NO.: __________ DATED: __________________________
A RESOLUTION AUTHORIZING APPLICATION
TO THE DIRECTOR OF INDUSTRIAL RELATIONS, STATE OF CALIFORNIA
FOR A CERTIFICATE OF CONSENT TO SELF-INSURE
WORKERS' COMPENSATION LIABILITIES
At a meeting of the _____________________________________________________
(Enter Name of the Board)
of the ________________________________________________________________
(Enter Name of Public Agency, District, Etc.)
a ______________________________________ organized and existing under the
(Enter Type of Agency, i.e., County, City, School District, etc.)
laws of the State of California, held on the _______ day of ______________, 20___,
the following resolution was adopted:
RESOLVED, that the above named public agency is authorized and empowered to
make application to the Director of Industrial Relations, State of California, for a
Certificate of Consent to Self-Insure workers' compensation liabilities and
representatives of Agency are authorized to execute any and all documents
required for such application.
IN WITNESS WHEREOF: I HAVE SIGNED AND AFFIXED THE AGENCY SEAL.
X_____________________________________________
DATE: __________________________________
SIGNED: Board Secretary or Chair
______________________________________________
Printed Name
______________________________________________
Title
Affix Seal Here
______________________________________________
Agency Name
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