California Code of Regulations
Title 10 - Investment
Chapter 5 - Insurance Commissioner
Subchapter 3 - Insurers
Article 20 - Standards Applicable to Workers' Compensation Claims Adjusters and Medical Billing Entities and Certification of those Standards by Insurers
Section 2592.08 - Insurer Annual Certification Form-Claims Adjusters and Medical-Only Claims Adjusters
Current through Register 2024 Notice Reg. No. 38, September 20, 2024
ANNUAL CERTIFICATION OF CLAIMS ADJUSTERS AND MEDICAL-ONLY CLAIMS ADJUSTERS
To the Insurance Commissioner of the State of California Pursuant to California Insurance Code Section 11761 and California Code of Regulations, Title 10, Sections 2592.02 and 2592.07
As the person or officer responsible for the claims operation of:
______________________________
(Name of Insurer)
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[] Insurance Company |
[] Self-Insured Employer |
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[] Third-Party Administrator |
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|
(Check One) |
|
I hereby certify the following regarding California workers' compensation claims:
1. The total number of persons adjusting claims on this insurer's behalf is: __________.
2. The total number of experienced or trained claims adjusters and medical-only claims adjusters adjusting claims on the insurer's behalf is: __________.
3. The percentage of experienced or trained claims adjusters and medical-only claims adjusters adjusting claims on the insurer's behalf is: __________%
4. All persons adjusting claims on behalf of this insurer are designated to do so or are in training.
5. The course of instruction provided for training of all claims adjusters and medical-only claims adjusters meets all requirements set forth in Article 20 (commencing with section 2592) of Subchapter 3, Chapter 5, Title 10, California Code of Regulations, and that all claims adjusters and medical-only claims adjusters have attended training for the required number of hours to be qualified to adjust workers' compensation claims.
I certify under the penalty of perjury under the laws of the State of California that the foregoing is true and correct:
| ___________________________ | ___________________________ | |
| (Date and Place) | (Signature) |
Name of person certifying (print or type):
Title of person certifying:
Business address:
1. New section filed 1-23-2006; operative 2-22-2006 (Register 2006, No. 4).
Note: Authority cited: Section 11761, Insurance Code. Reference: Section 11761, Insurance Code.
