Current through Register 2024 Notice Reg. No. 38, September 20, 2024
(a) Each private group of employers desiring
to procure a private group Certificate of Consent to Self-Insure as provided in
Section 15470 of these regulations shall
submit to the Chief a complete Application For A Certificate Of Consent To
Self-Insure By A Group Of Employers for the group and a complete Application
For An Affiliate Certificate Of Consent To Self-Insure As A Member Of A Group
Self-Insurer for each initial member of the group no less than 30 days before
the requested effective date of self-insurance. Applications shall be made on:
(1) Form S-1 (1-2016) for a private group
seeking a group Certificate of Consent to Self-Insure;
(2) Form S-2B (1-2016) for each member of a
group seeking an Affiliate Certificate of Consent to Self-Insure. The
Application for an Affiliate Certificate of Consent to Self-Insure shall be
completed as provided in Section
15482.1 of these
regulations.
(b) A
complete application to self-insure for a private group of employers shall be
submitted with complete applications for each initial proposed member of the
group and shall include the attachments requested in the application form
itself, and, as applicable, the following:
(1)
A duly executed Resolution by the Board of Trustees of the group applicant
authorizing execution of the application to become a group self-insurer and
empowering the Group Administrator and other employees, officers, or Trustees
of the group self-insurer applicant to sign the application form and other
necessary documents on behalf of the group self-insurer applicant;
(2) A duly executed Resolution by the Board
of Trustees of the group self-insurer applicant authorizing the execution of an
Agreement of Assumption and Guarantee Of Workers' Compensation Liabilities on
behalf of the proposed group members and any future members of the group
self-insurer granted an Affiliate Certificate;
(3) An Agreement of Assumption and Guarantee
of Workers' Compensation Liabilities For Group and Affiliate Members ((Form S-5
(1-2016)) executed by the applicant group self-insurer as required in Section
15483 of these
regulations;
(4) An original
Certificate of Status from the California Secretary of State or other
appropriate registration documents showing that the group applicant is
appropriately registered to do business in California dated within 90 days of
the date of receipt of the application by the Chief;
(5) A certification that the group has
implemented an effective injury and illness prevention program and contact name
of the person responsible for overseeing the group's safety services as
specified in Section
15486.1 of these
regulations;
(6) An original, duly
executed Indemnity Agreement and Power of Attorney of Joint and Several
Liability between the group self-insurer applicant and each proposed member
pursuant to Section
15479 of these
regulations.
(7) Payment of the
required application fee(s) as required by Section
15491 of these
regulations.
(8) A copy of the
Initial Feasibility Study Report as required in Section
15471 of these
regulations.
(9) A duly executed
Agreement and Undertaking for Security Deposit as required by Section
15486.
1. New
section filed 3-2-2009; operative 3-2-2009 pursuant to Government Code section
11343.4 (Register 2009, No. 10).
2. Amendment filed 12-14-2016;
operative 1-1-2017 pursuant to Government Code section 11343.4(b)(3) (Register
2016, No. 51).
Note: Authority cited: Sections
54,
55 and 3702.10, Labor Code.
Reference: Sections 59,
3700,
3701, 3701.5,
3702, 3702.2, 3702.5 and 3702.10,
Labor Code.
