Chapter 8. Office of the Director
Subchapter 2. Administration of Self-Insurance Plans
Article 13. Group Self Insurance

§ 15482. Private Group Application.

(a) Each private group of employers desiring to procure a private group Certificate of Consent to Self Insure as provided in Section 15470 of these regulations shall submit to the Manager a complete Application For A Certificate Of Consent To Self Insure By A Group Of Employers for the group and a complete Application For An Affiliate Certificate Of Consent To Self Insure As A Member Of A Group Self Insurer for each of the initial core members of the group no less than 60 days before the requested effective date of self insurance. Applications shall be made on:

(1) Form A4-3 (Rev. 1/94) for a private group seeking a group Certificate of Consent to Self Insure;

(2) Form A4-3M (Rev. 1/94) for each member of a group seeking an Affiliate Certificate of Consent to Self Insure. The Application for an Affiliate Certificate of Consent to Self Insure shall be completed as provided in Section 15482.1 of these regulations.

(b) A complete application to self insure for a private group of employers shall be submitted with complete applications for each initial proposed core members of the group and shall include the attachments requested in the application form itself, and, as applicable, the following:

(1) A current financial statement, together with all schedules and notes, for each proposed initial core member. Qualifying financial information for a private group member or applicant may be included in the consolidated financial statement of its parent company or owner if the parent or owner executes an Agreement of Assumption and Guarantee of Workers' Compensation Liabilities pursuant to Section 15211.2 of these regulations.

(2) A duly executed Resolution by the Board of Trustees of the group applicant authorizing execution of the application to become a group self insurer and empowering the Group Administrator and other employees, officers, or Trustees of the group self insurer applicant to sign the application form and other necessary documents on behalf of the group self insurer applicant;

(3) A duly executed Resolution by the Board of Trustees of the group self insurer applicant authorizing the execution of an Agreement of Assumption and Guarantee For Workers' Compensation Liabilities on behalf of the proposed group members and any future members of the group self insurer granted an Affiliate Certificate;

(4) An Agreement of Assumption and Guarantee of Workers' Compensation Liabilities For Group Members ((Form A4-3G (Rev. 1/94)) listing each initial proposed group member and executed by the applicant group self insurer as required in Section 15483 of these regulations;

(5) An original Certificate of Status from the California Secretary of State or other appropriate registration documents showing that the group applicant is appropriately licensed or registered to do business in California, with such documents dated within 90 days of the date of receipt of the application by the Manager;

(6) A written evaluation of the proposed qualifying core group members' injury and illness prevention programs or copy of a DOSH evaluation report as specified in Section 15486.1 of these regulations;

(7) An original, duly executed Indemnity Agreement and Power of Attorney of Joint and Several Liability between the group self insurer applicant and each proposed member pursuant to Section 15479 of these regulations.

(8) Payment of the required application fee(s) as required by Section 15491 of these regulations.

(9) A copy of the Initial Feasibility Study Report as required in Section 15471 of these regulations.

(10) A duly executed Agreement and Undertaking for Security Deposit as required by Section 15486.

   Note: Authority cited: Sections 54, 55 and 3702.10, Labor Code. Reference: Sections 59, 3700, 3701, 3701.5, 3702, 3702.2, 3702.5 and 3702.10, Labor Code.

 HISTORY 

   

1. New section filed 3-2-2009; operative 3-2-2009 pursuant to  GovernmentCode section 11343.4 (Register 2009, No. 10).