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 2592.12 - Designation-Experienced Claims Adjuster and Medical-Only Claims Adjuster

EXPERIENCED CLAIMS ADJUSTER OR EXPERIENCED MEDICAL-ONLY CLAIMS ADJUSTER DESIGNATION

This Designation is awarded to

______________________________

(Adjuster's Name)

for: [] Experienced Claims Adjuster

[] Experienced Medical-Only Claims Adjuster

(Check Only One)

as a result of meeting the experience requirements for workers' compensation claims experience pursuant to California Insurance Code Section 11761 and California Code of Regulations, Title 10, Sections 2592.01 and 2592.05

Total Years of California Experience At Time of Designation: ____________ and/or Date Completed Examination Pursuant to Title 8, CCR Section 15452: ____________

Designation Given By:

______________________________

(Name of Insurance Company, Self-Insured Employer, or Third-Party Administrator)

Name of person awarding designation (print or type):

Title of person awarding designation:

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.