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Chapter 8. Office of the Director
Subchapter 2. Administration of Self-Insurance Plans
Article 1. Definitions
The following definitions apply in Articles 1 through 13 of these regulations:
Actuarial Study. Also referred to as a 'study.' This is a complete actuarial study prepared by a qualified actuary presenting the full and complete results of the actuarial analysis and study performed by the actuary including, but not limited to, the requirements specified in section 15209 for private self-insurers or section 15481 for self-insured groups. The study will also serve as the basis for the completion of the actuarial summary and be attached to the actuarial summary.
Actuarial Summary. Also referred to as a 'summary.' This is a summary of the study prepared by the same qualified actuary that prepared the study. The summary is taken directly from the actuarial study, electronically filed with the Office of Self-Insurance Plans, and shall include the data specified in sections 15209 for private self-insurers or section 15481 for self-insured groups.
Adjusting Location. The office address designated in accordance with Section 15402 of these regulations where the named administrator of the self-insurer fulfills his/her function.
In the event that claims are administered at the home of a telecommuting adjuster, the location shall be considered as a separate adjusting location for reporting and audit purposes unless the telecommuting adjuster reports to a California location of the administrator no less than weekly.
Administrative Agency. The person or firm that performs the day-to-day claims administration functions of a workers' compensation self-insurance program. The administrative agency may be:
(1) An independent contractor possessing a certificate to administer and designated by a self-insurer to be the administrative agency for all or a portion of its claims; or
(2) A partnership or corporation possessing a master certificate to self-insure, which administers its own claims and the claims of other affiliate or subsidiary self-insurers issued affiliate or subsidiary certificates to self-insure under the same master certificate number;
(3) A joint powers authority possessing a master certificate to self-insure, which self administers in whole or part the claims of its affiliate public self-insurers issued affiliate certificates to self-insure under the same master certificate number of the joint powers authority; or
(4) The claims department of an insurance carrier admitted to transact workers' compensation insurance in California, which is exempt from the requirement to possess a certificate to administer under Labor Code Section 3702.1(a).
Administrative Director. The Administrative Director of the Division of Workers' Compensation within the Department of Industrial Relations.
Administrator. A competent person pursuant to Section 15452 of these regulations, at an adjusting location, who is responsible for day-to-day management of an employer's self-insurance workers' compensation program. The responsibility includes but is not limited to, the making and reviewing of decisions relating to the furnishing of all workers' compensation benefits in accordance with law and the maintenance of the self-insurer's claim records.
(1) A type of certificate to self-insure issued to a private self-insurer that has common ownership to another private self-insurer holding a master certificate to self-insure, but the affiliated certificate holder is not a subsidiary to the master certificate holder; or
(2) A type of certificate to self-insure issued to a public self-insurer that is a member of a joint powers authority for pooling of workers' compensation liabilities with the master certificate number issued to the joint powers authority.
(3) A type of certificate to self-insure issued to a private self-insurer that is a member of a group self-insurer for pooling of workers' compensation liabilities under the master certificate number issued to the group self-insurer.
Alternative Composite Deposit. A security deposit system pursuant to Labor Code Section 3701.8 whereby all eligible private self-insurers collectively secure, in whole or in part, aggregate self-insured worker's compensation liabilities through the Self-Insurer's Security Fund.
Audit. Any examination of self-insured workers' compensation claim files performed by or at the request of the Office of Self-Insurance Plans pursuant to Labor Code Section 3702.6.
Board of Trustees. In group self-insurance, the representative body in a group self-insurer selected by the group members to be responsible for managing the assets and directing the affairs of the group self-insurer corporation and assuring the group self-insurer, through the group members, is financially sound and able to meet the workers' compensation liabilities under the statutes and regulations applicable in California.
Cancellation of Surety Bond. An act whereby the surety gives written notice to the Chief, as beneficiary of the workers' compensation self-insurance surety bond, that the surety is terminating its contractual obligations under the named bond pursuant to Sections 996.320 and 996.330 of the California Code of Civil Procedure and the liability of the surety bond after the effective date of the cancellation is set forth in Section 996.360 of the California Code of Civil Procedure.
Certificate to Administer. A Certificate of Consent to Administer self-insured workers' compensation claims issued to an administrative agency, except exempt insurance carriers, pursuant to Labor Code Section 3702.1.
Certificate to Self-Insure. A Certificate of Consent to Self-Insure issued to an employer pursuant to Section 3700(b) of the Labor Code.
Chief. The Chief, Office of Self-Insurance Plans, in the Department of Industrial Relations.
Claim File. A case file containing all pertinent documents and matters relating to a specific work-injury claim. The claim file contents are specified in Section 15400 of these regulations.
Claim Log. A manual or electronic listing of workers' compensation claims maintained by the self-insurer or administrative agency for the self-insurer. The claim log for private self-insurers shall list each work injury claim by the calendar year in which the claim was reported to the employer or the claims administrator, whichever first occurred. The log for public self-insurers shall list each work injury claim by the fiscal year in which the claim was reported. The claim log contents are specified in Section 15400.1 of these regulations.
Closed Claim. A work-injury claim in which future provision of benefits cannot be reasonably expected to be due.
Compensation. Compensation as defined in Labor Code Section 3207, which includes every benefit or payment conferred by Division 4 of the Labor Code on an injured employee or the employee's dependents.
Contribution. The amount of payments required of each group member in order to fund the compensation and deposit obligations of the group self-insurer.
Director. The Director of the Department of Industrial Relations.
Exoneration of Surety Bond. The discharge of a surety from all past, present and future liability under its workers' compensation self-insurance surety bond by the execution of a "Release of Surety". Form A4-24 (Rev. 11/92) by the Chief.
First Aid. First Aid as defined in Labor Code Section 5401(a).
Group Administrator. The individual or business entity authorized to serve as the representative of a group self-insurer and its group members to execute the policies of the Board of Trustees of the group self-insurer and manage the activities of the group self-insurer corporation.
Group Member. A private employer issued an Affiliate Certificate as a member in a group self-insurance program that has, in turn, been issued a Certificate to Self-Insure as a group self-insurer.
Group Self-Insurer. A private, non-profit, mutual benefit corporation, a private, non-profit charitable corporation, a private, non-profit public benefit corporation, or a private, non-profit religious corporation created as set forth in Section 15470 of these regulations and pursuant to Part 3 of Division 2 of Title 1 of the California Corporation Code. Said corporation shall be established for the sole purpose of operating a group workers' compensation self-insurance program to pool the California workers' compensation liabilities of two or more private employers in the same homogeneous grouping pursuant to Section 15473. These regulations are not intended to deem a group self-insurer issued a Certificate of Consent to Self-Insure pursuant to Labor Code Section 3700, subdivision (b) to be an insurance company subject to regulations governing insurers contained in Title 10, California Code of Regulations, except as otherwise provided by statute and by Title 8, California Code of Regulations.
Indemnity Agreement and Power of Attorney. The written agreement executed by each group member or proposed group member of a group self-insurer pursuant to Section 15479 of these regulations.
Indemnity Claim. A work-injury case which has or may result in any of the following benefits:
(1) Temporary Disability or salary in lieu thereof, including benefits provided under Labor Code Sections 4800 and 4850
(2) Permanent Disability
(3) Life Pension
(4) Death Benefits
(5) Vocational Rehabilitation
(6) Supplemental Job Displacement Benefit Voucher
Industry. Employer classification as determined using the first three (3) digits of the North American Industry Classification System Code (NAICS Code), provided by the United States Department of Commerce, Bureau of Management and Budget.
Joint Powers Authority. A public entity created by agreement of two or more public agencies pursuant to Division 7, Chapter 5, Article 1, Sections 6500 et seq. of the California Government Code. These regulations apply only to Joint Powers Authorities who have among their purposes for existence, the forming of workers' compensation liability pooling arrangements.
Labor Code. The Labor Code of the State of California.
Manager. The Manager, Office of Self-Insurance Plans, in the Department of Industrial Relations. (Synonymous with Chief, above.)
Medical-Only Claim. A work-injury case which does not result in compensable lost time but results in medical treatment beyond first aid.
Note: Payment of medical examinations pursuant to Labor Code Section 4600 will be considered a medical payment.
Office of Self-Insurance Plans. The Department of Industrial Relations, Office of Self-Insurance Plans, that is responsible for the oversight and regulation of Workers' Compensation self-insurance programs under these regulations.
Open Claim. A work-injury case in which it appears that one or more future payments of workers' compensation benefits may be due.
Public Self-Insurer or Public Self-Insured Employer.
(1) Any county, city, school district, special purpose district, joint powers authority or other municipal corporation which has applied and received approval to be self-insured by the Office of Self-Insurance Plans.
(2) Any sub-agency of a public agency which is created by or pursuant to statute, ordinance, or other legislative act, including but not limited to planning commissions, library or park boards, commissions, and agencies which has applied and received approval to be self-insured by the Office of Self-Insurance Plans.
Qualified Actuary. A qualified actuary is any actuary that meets the minimum standards of experience, certification, licensure, insurance, and qualifications set forth in section 15209, subdivisions (a)(2) and (3), for private self-insurers or section 15481, subdivisions (a)(3) & (4), for self-insured groups.
Release of Surety Bond. Action of Chief of Self-Insurance Plans by which a surety is exonerated. A released surety bond does not constitute part of the security deposit of a self-insured entity.
Security Fund. The Self-Insurer's Security Fund as established by Labor Code section 3742.
Self-Insurer. An individual public or private sector employer or joint powers authority or private group of employers that has been issued and lawfully holds a valid Certificate to Self-Insure its workers' compensation liabilities pursuant to:
(1) The provisions of Section 29(a), Chapter 586, Laws of 1917 and amendments thereto; and/or
(2) Labor Code, Section 3700(b) for private sector employers or 3700(c) for public sector employers.
Special Audit. Any audit performed other than that in accordance with Labor Code Section 3702.6.
Subsidiary Certificate. A type of certificate to self-insure issued to a subsidiary of a self-insurer, where the self-insurer holds the master certificate to self-insure.
Termination of Surety Bond. See definition of "Cancellation of Surety Bond".
Work-Injury Claim. An injury that is reported or reportable to the Division of Labor Statistics and Research pursuant to Labor Code Sections 6409, 6409.1 and 6413.
Note: Authority cited: Sections 54, 55, 3701.8 and 3702.10, Labor Code. Reference: Sections 59, 129, 3700, 3701, 3701.5, 3701.8, 3702, 3702.3, 3702.5, 3702.6, 3702.10, 3703, 3705, 3740-3747 and 3850, Labor Code; Section 6500, Government Code; and Sections 995.430, 996.320 and 996.330, Code of Civil Procedure; and 5002, 5003, 5059, 5060, 5061 and 5080, Corporations Code.
1. Repealer and new section filed 12-3-69; effective thirtieth day thereafter (Register 69, No. 49).
2. Repealer and new section filed 6-1-72; effective thirtieth day thereafter (Register 72, No. 23).
3. Repealer and new section filed 11-19-75; effective thirtieth day thereafter (Register 75, No. 47).
4. Amendment placing the defined terms in alphabetical order, removal of letter designators, amendment of existing terms, addition of terms "Administrative Director," "Affiliate Certificate," "Certificate to Administer," and "Joint Powers Authority" and addition of Note filed 12-22-92; operative 1-21-93 (Register 93, No. 2).
5. New definitions "Cancellation of Surety Bond," "Exoneration of Surety Bond," "Release of Surety Bond," and "Termination of Surety Bond" and amendment of Note filed 8-12-93; operative 9-13-93 (Register 93, No. 33).
7. Amendment of section and Note filed 5-30-2003 as an emergency; operative 5-30-2003 (Register 2003, No. 22). A Certificate of Compliance must be transmitted to OAL by 9-29-2003 or emergency language will be repealed by operation of law on the following day.
8. Certificate of Compliance as to 5-30-2003 order transmitted to OAL 9-29-2003 and filed 11-12-2003 (Register 2003, No. 46).
9. Amendment of subsections (a)(2) and (m) filed 2-9-2006; operative 3-11-2006 (Register 2006, No. 6).
10. Amendment of subsections (e)(3), (h)-(i), and (m); new subsection (p), subsection relettering, amendment of newly designated subsections (t), (v), (y)-(z)and (gg)(2) and amendment of Note filed 3-2-2009; operative 3-2-2009 pursuant to Government Code section 11343.4 (Register 2009, No. 10).
12. Amendment of subsections (i), (bb) and (ee) and new subsections (ll )-(pp)(2) filed 12-31-2012 as an emergency; operative 1-1-2013 pursuant to Government Code section 11346.1(d) (Register 2013, No. 1). A Certificate of Compliance must be transmitted to OAL by 7-1-2013 or emergency language will be repealed by operation of law on the following day.
13. Certificate of Compliance as to 1-1-2013 order, including additional nonsubstantive amendments, transmitted to OAL 7-1-2013 and filed 8-13-2013 (Register 2013, No. 33).
14. Amendment of definitions of "Adjusting Location," "Claim File," "Compensation," "Group Self-Insurer," "Indemnity Claim" and "Industry," new definitions of "Closed Claim" and "Office of Self-Insurance Plans" and repealer of definition of "Core Group" filed 12-14-2016; operative 1-1-2017 pursuant to Government Code section 11343.4(b)(3) (Register 2016, No. 51).