(1) The
application shall contain the following:
(A) The
sole employer's complete name.
(B) The
sole employer's current business address including unit number, street, city,
county, state, and zip code.
(C) The
address to which the bills for the sole employer's premiums are to be sent, if
different from (B).
(D) The sole
employer's federal tax identification number.
(E) The sole employer's telephone
number.
(F) The industry type of the
sole employer.
(G) A copy of the sole
employer's most recent state Employment Development Department's (EDD) Form DE6
(entitled "Quarterly Wage Report") Form DE 3B (entitled "Report of Wages") or Form
DE 3DP (entitled "Quarterly Contribution Report") as submitted to EDD and a copy of
the Federal W-4 form or employer payroll records for any employee not listed on the
EDD forms submitted to the program.
(H)
The name and address of the sole employer's worker's compensation carrier, and the
policy number.
(I) The number of
eligible employees, or employees who will be eligible by the effective date of
coverage, employed by the sole employer and the number of eligible employees, or
employees who will be eligible by the effective date of coverage, applying for
enrollment in the program.
(J) A
notification to the program of persons, if any, who can be demonstrated to have
legal access to replacement coverage pursuant to California Insurance Code Section
10128.3 or
California Health and Safety Code Section
1399.63.
(K) A declaration that the sole employer has
informed every potential sole employee of the opportunity to obtain coverage from
the participating carriers in the program and that each potential sole employee was
given at least thirty (30) calendar days to respond to the opportunity.
(L) A declaration that the sole employer will
inform and invite potential sole employees to respond in a consistent time and
manner.
(M) A declaration that 100% of
the eligible employees enrolling in the program legally required to be covered by
workers' compensation insurance are so covered.
(N) A declaration that each of the employees
applying for enrollment in the program is an eligible employee or will be an
eligible employee by the effective date of coverage.
(O)
(1) For sole
employers who have an effective date of coverage prior to September 1, 1998, who
have not made an election pursuant to Section
2699.6116, a declaration that the
employer will contribute an amount equal to at least 50% of the lowest available
employee only rate for each applying employee. If the sole employer will contribute
100% of the employee only rate, the declaration must so state.
(2) For sole employers who have an effective date
of coverage on or after September 1, 1998, or who have made an election pursuant to
Section 2699.6116, a declaration that the
employer will contribute an amount equal to at least 50% of the lowest available
employee only comprehensive individual medical premium for each applying employee.
If the sole employer will contribute 100% of the employee only comprehensive
individual medical premium, the declaration must so state.
(P) For sole employees with four (4) or more
eligible employees, a declaration that at least 70% of the eligible employees, or
employees who will be eligible as of the effective date of coverage, are applying
for enrollment in the program. If the sole employer contributes 100% of the
"employee only" rate or the "employee only" comprehensive individual medical premium
or if the sole employer has two (2) or three (3) eligible employees, a declaration
that 100% of employees who will be eligible employees as of the effective date of
coverage, are applying for enrollment.
(Q) A declaration that the sole employer will
abide by the rules of participation and premium payment requirements of the
program.
(R) A declaration that those
eligible employees who have declined coverage in the program for themselves or for
any of their dependents have signed a form explaining to them that they will be
unable to enroll in the program until the program's next open enrollment
period.
(S) A declaration by a legally
authorized representative of the sole employer stating that the information is
accurate and complete to the best of their knowledge.
(T)
(1) For sole
employers who have an effective date of coverage prior to September 1, 1998 who have
not made an election pursuant to Section
2699.6116, either the agent/broker
payment request specified in Section
2699.6194(a)(1) or the
sole employer certification specified in Section
2699.6194(a)(2).
(2) For sole employers who have an effective date
of coverage on or after September 1, 1998 or who have made an election pursuant to
Section 2699.6116, the agent/broker payment
request specified in Section
2699.6194(b)(2).
(2) The sole employer shall submit information for
each eligible employee who is applying for enrollment that includes the following:
(A) The employee's full name.
(B) The employee's current residence address
including house or unit number, street, city, county, state, and zip code.
(C) The employee's home and work phone
numbers.
(D) The employee's date of
birth.
(E) The employee's sex.
(F) The employee's social security number, as
defined in Section
2699.6000.
(G) The employee's medical insurance information,
including the carrier name and address of:
1. Any
current medical insurance or other health benefits including coverage under the
federal Medicare program pursuant to Title XVIII,
2. Most recent prior medical insurance or other
health benefits.
(H) The
employee's date of employment with the sole employer, the number of hours in the
employee's normal workweek, and the date, if different from the employment date,
that the employee began a normal workweek of at least thirty (30) hours.
(I) If dependents are to be included in the
coverage, the full names, dates of birth, sex, social security numbers as defined in
Section 2699.6000, if available, relationship
of the dependents to be covered and medical insurance information for each dependent
as specified in (G) above.
(J) The
participating carrier and health benefits plan that the eligible employee is
selecting for coverage.
(K) A signed and
dated declaration by the eligible employee that declares the following:
1. The employee will follow the rules and
regulations of the program.
2. The
employee has reviewed the services and coverage offered by the participating
carriers and the premium rates of the participating carriers.
3. The employee resides in the service area of
his/her selected participating carrier.
4. The employee will abide by the rules,
utilization review process, and dispute resolution process of the participating
carrier which the eligible employee has selected.
5. The employee understands that he or she meets
the program requirements to be an eligible employee.
6. The information given is true and
correct.
