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

§15482.1. Private Group Member Application.

(a) A complete group member application to self insure on a (Form A4-3M (Rev. 1/94)) by each member of a group self insurer shall include all the attachments requested in the application form itself, and, as applicable, the following:

(1) A current financial statement together with all schedules and notes if the applicant group member will be considered a core group member as defined in Section 15201(p) of these regulations. For applications for non-core members of a group self insurer that has qualified financially to self insure pursuant to Section 15472, no financial statement need be submitted with the application. However, the Board of Trustees, or the Group Administrator if authorized by the group bylaws, shall evaluate potential new members by reviewing their financial statements, tax returns, credit reports, or other appropriate documentation as specified in the bylaws of the group self insurer.

(2) A duly executed Resolution authorizing completion of the application to become self insured as a member of the group self insurer;

(3) A duly executed Indemnity Agreement and Power of Attorney (Form A4-8 (Rev. 1/94)), as required by Section 15479 of these regulations;

(b) Notwithstanding subsection (a)(1), at the discretion of the Manager, an employer with projected contributions of 25% or more of the group self insurer's projected total contributions for the coming program year shall be required to submit a financial statement to the Manager.

(c) A separate application shall be submitted for any new or separate subsidiary or affiliate of an affiliate group self insurer in order for it to be considered for consent to self insure.

(d) A new application may be required whenever an existing affiliate group self insurer reincorporates, merges, or otherwise changes ownership.

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