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Chapter 8. Office of the Director
Subchapter 2. Administration of Self-Insurance Plans
Article 2. Certificate to Self Insure

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§15203. Application.

(a) Application forms for individual Certificates of Consent to Self Insure and other required self insurance forms are available on the website of the Office of Self Insurance Plans at http://sip.dir.ca.gov/. Every employer desiring to procure an initial, individual private or public certificate to self insure its workers' compensation liabilities shall make application on:

  (1) Form A4-1 (Rev. 2/92) for private individual employer applicants seeking an individual Certificate to Self Insure;  


  (2) Form A4-2 (Rev. 2/92) for public employer applicants;  


  (3) Form A4-5 (Rev. 11/97) for an interim self insurer seeking a permanent Certificate to Self Insure.  


(b) A new application may be required when an existing, individual self insurer reincorporates, merges, changes ownership, or adds a new or separate subsidiary or affiliate to its existing workers' compensation self insurance program. In some cases, it may be possible to amend and transfer an existing certificate without a new application.

(c) A complete application to self insure by an individual, private employer (Form A4-1 (Rev. 2/92)) shall include all attachments requested on the application form itself, and, as applicable, the following:

  (1) A current, certified, independently audited financial statement complete with all schedules and notes for the past three years.  


  The application of a private sector subsidiary or affiliate may include the consolidated financial statement of its parent in lieu of the subsidiary's financial statement;  


  (2) An unaudited financial statement or published quarterly report, or a consolidated financial statement for the current year or portion thereof;  


  (3) An Agreement of Assumption and Guarantee of Liabilities for each self insurer and subsidiary or affiliate applicant executed by the parent employer or majority owner, or partners;  


  (4) A Resolution authorizing the application to self insure and empowering employees or officers of the applicant employer to sign the application form and any other necessary documents on behalf of the applicant employer;  


  (5) A Resolution by the general partners, or parent corporation authorizing the execution of the Agreement of Assumption and Guarantee of Liabilities on behalf of a subsidiary or affiliate applicant employer;  


  (6) Original Certificates of Status or other appropriate registration documents showing that the applicant employer is licensed or registered to do business in California;  


  (7) A written evaluation of the applicant's injury and illness prevention program or proof of a DOSH inspection pursuant to Section 15353 of these regulations; and  


  (8) Payment of any required application filing fee.  


(d) A complete application to self insure by a public employer (Form A4-2) (Rev. 2/92) shall include all attachments requested on the public sector application form and, as applicable, the following:

  (1) An Agreement of Assumption and Guarantee of Liabilities for the predecessor agency due to a unification, merger, realignment of the boundaries of an existing self insured public agency, or name change by the successor or surviving public agency;  


  (2) A Resolution authorizing the application to self insure and empowering employees or officers of the applicant employer or joint powers authority to sign the application form and any other necessary documents on behalf of the applicant.  


  (3) Each public applicant shall indicate the proposed start up date of its self insurance program as part of its application.  


(e) A complete application to self insure on a Form A4-3 by a private group of employers shall include all information and documents as indicated in Section 15482 of these regulations.

(f) A complete application to self insure on a Form A4-3M (Rev. 1/94) by each member of a group shall include all information as indicated in Section 15482.1 of these regulations.

(g) The Manager shall issue a Certificate of Consent to Self Insure to an approved joint powers authority that pools the workers' compensation liabilities of its public agency members and the master certificate number shall be assigned to the joint powers authority. Each approved member of the joint powers authority shall be issued an affiliate certificate numbers under the certificate number issued to the joint powers authority.

(h) Upon receipt of a complete private individual employer application, the applicant will be notified within 45 days of the Director's decision to allow or deny self insurance or to advise that the application is deficient. A notice indicating that the application is deficient will include a list of items required to be included or completed.

(i) Upon receipt of a complete public entity application, the applicant will be notified within 30 days of approval or denial of application.


     Note: Authority cited: Sections 54, 55, 59 and 3702.10, Labor Code. Reference: Sections 3700, 3700(b), 3701, 3702, 3702.5 and 6401.7(a), Labor Code.  


 HISTORY 
   
1. Repealer and new section filed 6-1-72; effective thirtieth day thereafter 
(Register 72, No. 23).

2. Amendment filed 11-19-75; effective thirtieth day thereafter (Register 75, 
No. 47).

3. Amendment filed 11-21-78; effective thirtieth day thereafter (Register 78, 
No. 47).

4. New article 2 heading, newly designated subsections (a) and (b)-(b)(1), new
subsections (b)(2)-(g)(1), amendment of Note, and repealer of form filed 12-22-
92; operative 1-21-93 (Register 93, No. 2).

5. Amendment filed 6-30-94; operative 6-30-94 (Register 94, No. 26).

6. Amendment of subsection (a)(4), new subsection (a)(5), amendment of Note1
and amendment of subsections (g) and (h) filed 6-4-98; operative 7-4-98 
(Register 98, No. 23).

7. Amendment of article heading, section heading, section and Note filed 3-2-
2009; operative 3-2-2009 pursuant to Government Code section 11343.4 
(Register 2009, No. 10).

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