(a) The Corporate Resolution to authorize self-insurance of workers' compensation (Form A-5 (1-2016)) required pursuant to Section 15203(c) of these regulations as part of the application for a certificate to self-insure by any individual private employer shall be adopted by the private employer's Board of Directors or the general partners of an applicant partnership or joint venture, or owner of an applicant sole proprietorship. The resolution to authorize self-insurance shall include the following:
(1) A statement identifying the applicant by corporate or other legal name, the state of registration, and the date that the resolution was adopted;
(2) Identification by title of appointed officers or other company employees authorized to sign the application, execute any and all documents required for the application, and do subsequent acts required to maintain self-insurance approval.
(b) If an individual private self-insurer reincorporates, merges, or changes its identity, a new resolution shall be submitted to the Chief within 30 days of the change. The resolution shall confirm and authorize the maintenance of the self-insurer's responsibility under the successor's identity. The Chief may extend the period of time to submit the resolution for good cause.
(c) The Chief shall provide a model Corporate Resolution (Form A-5 (1-2016)) as part of the application form and will provide a model resolution for a non-corporate entity upon request.
Note: Authority cited: Sections 54, 55 and 3702.10, Labor Code. Reference: Sections 59, 3700, 3701, 3702 and 3702.10, Labor Code.
1. New section filed 11-21-78; effective thirtieth day thereafter (Register 78, No. 47).
2. Amendment filed 1-19-79; effective thirtieth day thereafter (Register 79, No. 3).
3. Amendment of section heading and text filed 12-22-92; operative 1-21-93 (Register 93, No. 2).
4. Amendment of section heading and text filed 6-30-94; operative 6-30-94 (Register 94, No. 26).
5. Amendment of section heading and section filed 3-2-2009; operative 3-2-2009 pursuant to Government Code section 11343.4 (Register 2009, No. 10).
6. Amendment of section heading and section filed 12-14-2016; operative 1-1-2017 pursuant to Government Code section 11343.4(b)(3) (Register 2016, No. 51).