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Chapter 8. Office of the Director
Subchapter 2. Administration of Self-Insurance Plans
Article 13. Group Self-Insurance
(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 Chief 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 initial member of the group no less than 30 days before the requested effective date of self-insurance. Applications shall be made on:
(1) Form S-1 (1-2016) for a private group seeking a group Certificate of Consent to Self-Insure;
(2) Form S-2B (1-2016) 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 member of the group and shall include the attachments requested in the application form itself, and, as applicable, the following:
(1) 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;
(2) 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 Of Workers' Compensation Liabilities on behalf of the proposed group members and any future members of the group self-insurer granted an Affiliate Certificate;
(3) An Agreement of Assumption and Guarantee of Workers' Compensation Liabilities For Group and Affiliate Members ((Form S-5 (1-2016)) executed by the applicant group self-insurer as required in Section 15483 of these regulations;
(4) An original Certificate of Status from the California Secretary of State or other appropriate registration documents showing that the group applicant is appropriately registered to do business in California dated within 90 days of the date of receipt of the application by the Chief;
(5) A certification that the group has implemented an effective injury and illness prevention program and contact name of the person responsible for overseeing the group's safety services as specified in Section 15486.1 of these regulations;
(6) 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.
(7) Payment of the required application fee(s) as required by Section 15491 of these regulations.
(8) A copy of the Initial Feasibility Study Report as required in Section 15471 of these regulations.
(9) A duly executed Agreement and Undertaking for Security Deposit as required by Section 15486.