Current through Register 2024 Notice Reg. No. 38, September 20, 2024
(a) Each self-insurer shall file a
Self-Insurer's Annual Report every year as required by subsections (b) through
(g) of this section and shall continue to file a Self-Insurer's Annual Report
annually after revocation of the Certificate of Consent to Self-Insure until a
final Self-Insurer's Annual Report has been filed showing all claims have been
closed and there are no remaining claims with the expectation of future
liabilities. Each year no later than sixty (60) days before the deadline for
filing the Self-Insurer's Annual Report pursuant to subsection (b) or
subsection (c) of this section, whichever applies, the Chief shall post the
Annual Report form, along with instructions for completing the form and showing
the years to be reported, on the website of the Office of Self-Insurance Plans
at http://www.dir.ca.gov/osip.
Each self-insurer shall file a Self-Insurer's Annual Report via an on-line
platform provided by OSIP as follows:
(1) Form
AR-1 (1-2016) for individual private and private group self-insurers;
(2) Form AR-2 (rev. 1-2020) for all public
self-insurers, including those that are members of a Joint Powers
Authority;
(b) For
private self-insurers, individual or with a group, the report shall be filed on
or before March 1 of each year and shall include the following information:
(1) General Information.
(A) Certificate to Self-Insure number, status
of certificate, and period of report.
(B) Name and address of master certificate
holder, state of incorporation, federal tax identification number, and first
three (3) digits of North American Industry Classification System
(NAICS).
(C) List of all
subsidiaries or affiliate companies that are covered by the master certificate
to self-insure, their state of incorporation, and their subsidiary/affiliate
certificate number.
(D)
Notification of any reincorporation, merger, change in name or identity or any
additions to the self-insurance program by the master certificate holder or any
subsidiary/affiliate company during the reporting period.
(E) Name and address of person to whom all
correspondence related to self-insurance should be addressed.
(F) Employment and wages paid in that
calendar year as reported to Employment Development Department on the
employer's Form DE-9 Quarterly Report or other similar Employment Development
form used to report employment and wages in that calendar year.
EXCEPTION: A Certificate to Self-Insure that is revoked
for three full years is not required to submit this employment and wage
information.
(2)
Claims Liability and Administrator Information.
A Liabilities by Reporting Location report shall be
submitted by each claims administrator administering claims for the said
self-insurer and shall include:
(A)
All claims reported on or before December 31 of each of the five (5) prior
calendar years (January 1 through December 31), showing indemnity and medical
payments grouped as incurred liability, paid to date and future
liability.
(B) All open claims
reported prior to the five (5) years shall also be reported as in subsection
(b)(2)(A), but in a single line entry;
(C) For the reporting year of the annual
report the total of indemnity and medical future liability, the total estimated
future liability of claims, the total benefits paid, number of medical only
cases reported, number of indemnity cases reported; number of fatality cases,
number of claims for which the employer or administrator was notified of
representation by an attorney or legal representative in the reporting year,
and number of new applications for adjudication received for any claims that
year.
(D) Total number of open
indemnity cases in all years.
(E)
Name, address and Certificate to Administer number of the self-insurer's claims
administrator.
(F) Notification of
any change in administrator during the period covered by the report and, if
applicable, the name and address of the prior administrator.
(G) A certification by the qualified claims
administrator that the report is true, correct and complete with respect to the
workers' compensation liabilities incurred and paid, signed and dated with the
name and address of the said administrator completing the Liabilities by
Reporting Location page.
(3) Location of Claims Records Information.
The name and address of any location other than the current administrator where
self-insurance claims records are stored.
(4) Insurance Information. Name and policy
number of any standard workers' compensation insurance policy, specific excess
workers' compensation insurance policy, or aggregate worker's compensation
insurance policy held by the self-insurer along with policy issue date and
retention levels of liability of the policies.
(5) Open Indemnity Claims Information. A list
of all open indemnity claims by reporting location by year, and alphabetically
within each year. The list shall:
(A) Show the
name of each claimant, date of injury, description of injury, amount of
benefits paid-to-date in indemnity and medical payments and estimated future
liability of claim for indemnity and medical benefits.
NOTE: Computer Loss Runs showing the information
requested and organized as set forth in this subsection will be acceptable in
lieu of the List of Open Indemnity Claims.
(B) Show any open claim reported to the
carrier of a specific excess insurance policy, and for which the carrier has
not denied in writing the claim liability in whole or part above the retention
level of the policy. The list shall include the name of the claimant, claim
number, date of injury, description of injury, carrier name and policy number,
policy coverage period, retention level of policy and paid to date in indemnity
or medical benefits, and the estimated future liability of the claim minus the
total unpaid employer retention, which equals the total unpaid carrier
liability. The list shall also indicate whether the claim has been reported to
a carrier, if the claim has been accepted by the carrier, if the carrier has
denied any part of the liability of the claim.
(6) Specific Excess Coverage Calculation. A
calculation which includes a total of all unpaid carrier liability.
(7) Company Officer Certification
Information. The name, title, address, phone number and signature of the
company officer authorized to certify that the report is true, correct and
complete and acknowledging the company's responsibility to post and maintain
the required security deposit that is due as a result of this
report.
(c) For all
public self-insurers, whether or not a member of a joint powers authority, the
report shall be filed by October 1 of each year to cover liabilities during the
July 1-June 30 fiscal year and shall include:
(1) General Information.
(A) Name and address of master certificate
holder (individual agency or joint powers authority as applicable), federal
employer identification number, and type of public agency.
(B) Agency name and certificate numbers of
all of the joint powers authority's members.
(C) A certification by the individual public
agency or joint powers authority official that the report is true, correct and
complete.
(D) Notification of any
reincorporation, merger, change in name or identity or any additions to the
self-insurance program by the master certificate holder or any
subsidiary/affiliate company during the reporting period, and identification of
any employees not included in the self-insurance program.
(E) Name, address, telephone number, and
email address of person to whom all correspondence related to self-insurance
should be addressed.
(F) Employment
and wages paid in that fiscal year as reported to Employment Development
Department on the employer's Form DE-9 Quarterly Report or other similar
Employment Development form used to report employment and wages in that fiscal
year.
EXCEPTION: A public employer whose Certificate of Consent
to Self-Insure has been revoked is not required to submit employment and wage
information.
(2)
Liability Report and Administrator Information.
A Liabilities Report which shall include:
(A) All claims reported shall be on a fiscal
year basis (starting July 1 and ending June 30 of the reporting years), with
all claims reported on or before June 30 of each of the five prior fiscal
years, showing indemnity and medical payments grouped as incurred liability,
paid to date and future liability.
(B) All open claims reported prior to the
five years shall also be reported as required in (b)(2)(A), but in a single
line entry.
(C) Each Joint Powers
Authorities (JPA) shall report the consolidated liabilities of all members of
the JPA on one Liabilities Report.
(D) A Liabilities by Reporting Location
Report shall be completed in full for each claims adjusting location in
addition to the consolidated report totaling liabilities from all
locations.
(E) For any Joint Powers
Authority, one list of all open indemnity claims may be consolidated into a
single listing for the entire JPA, as long as the individual JPA member is
identified for each claim.
(3) Claims Information for each year shall
meet the requirements of subsection (b), except that no deposit calculation
page shall be submitted as required for private self-insurers pursuant to
subsection (b)(7).
(4) Aggregate
Claims Information. Specify for claims in the current fiscal year and in each
of the past five fiscal years, and for claims reported prior to the five years
in a single line entry, aggregate amounts for each of the indicated categories
on Form AR-2, showing the number of claims, amount of disability benefits paid,
amount of medical costs paid, legal and loss adjustment expenses paid, and
estimated future liabilities. Figures must reflect amounts paid and number of
claims, as specified on the Aggregate Claims Information portion of Form AR-2
during the reporting year, as of the end of the indicated fiscal year of the
date of loss, for the life of the claim to date of the report.
(5) The claims information required by Form
AR-2 may be submitted electronically or by hard copy that includes the same
data elements required by Form AR-2. An Appendix of terms used in Public
Self-Insurer Report Forms P-1, J-1, and AR-2 follows section
15203.11.
(d) The Chief may, for good cause, require
any self-insurer to submit a Self-Insurer's Annual Report covering a six-month
interim period, in addition to the annual report specified in subsection (b)
and (c) of this section.
(1) For private
self-insurers, such interim reports, when required, shall cover the period
starting January 1 and ending June 30 of each year and shall be due on
September 1 of each year.
(2)
Public self-insurer's interim reports shall cover July 1 through December 31
and shall be due on March 1 of each year.
(e) The Chief shall assess the civil penalty
set forth in Labor Code Section
3702.9(a)
against any self-insurer for failure to file a complete and timely
Self-Insurer's Annual Report. Continued failure to file an Annual Report sixty
(60) days after assessment of civil penalties pursuant to Section 3702.9(a)
shall be good cause for revocation of a certificate to self-insure.
(f) For good cause shown by the self-insurer
or its administrative agency, the Chief may grant additional time to a
self-insurer to file the report without penalty.
(g) Unless otherwise approved by the Chief,
the consolidated liabilities report and reporting location reports (page 3 of
the annual report) shall be signed by a competent person, as demonstrated
pursuant to Section
15452(b) of these
regulations, in the employment of the self-insurer or administrative agency for
the self-insurance plan.
(h) The
employer's certification on the Self-Insurer's report shall be signed by:
(1) an officer or employee of the
self-insurer authorized to sign documents for self-insurance matters;
or
(2) an authorized public
self-insurer officer or employee; or
(3) an authorized officer or employee of the
joint powers authority to which the public agency is a member; or
(4) an authorized officer or employee of the
Self-Insurer's Security Fund where the Director has turned over responsibility
for an insolvent private self-insurer's claim liability to the Fund pursuant to
Labor Code Section
3701.5(c).
1.
Amendment filed 6-1-72; effective thirtieth day thereafter (Register 72, No.
23).
2. Amendment of section heading and text filed 10-16-92;
operative 11-16-92 (Register 92, No. 42).
3. Amendment of
subsections (a) and (b)(5)(B) and new subsection (b)(5)(B)1 filed 8-10-93;
operative 8-10-93 (Register 93, No. 33).
4. Amendment of subsections
(a)-(b), (b)(1)(F) EXCEPTION and (b)(5)(B) filed 6-30-94; operative 6-30-94
(Register 94, No. 26).
5. Change without regulatory effect amending
subsections (b)(1)(F) and (c)(1)(F) filed 10-18-95 pursuant to section
100, title 1, California Code of
Regulations (Register 95, No. 42).
6. Amendment filed 5-7-2001;
operative 6-6-2001 (Register 2001, No. 19).
7. Change without
regulatory effect amending subsection (a)(1) and form A4-40a (incorporated by
reference) filed 8-1-2001 pursuant to section
100, title 1, California Code of
Regulations (Register 2001, No. 31).
8. Change without regulatory
effect amending subsection (b)(2)(A)(7.) filed 4-7-2003 pursuant to section
100, title 1, California Code of
Regulations (Register 2003, No. 15).
9. Amendment of section and
NOTE filed 3-2-2009; operative 3-2-2009 pursuant to Government Code section
11343.4
(Register 2009, No. 10).
10. Amendment of subsections (b)(1)(F) and
(c)(1)(F) filed 9-19-2011; operative 10-19-2011 (Register 2011, No.
38).
11. Amendment of section heading and section filed 12-14-2016;
operative 1-1-2017 pursuant to Government Code section
11343.4(b)(3)
(Register 2016, No. 51).
12. Amendment of subsections (a)(2) and
(c)(1)(E) and new subsections (c)(4)-(5) filed 5-14-2020; operative 7-1-2020
(Register 2020, No. 20).
Note: Authority cited: Sections
54,
55 and
3702.10, Labor
Code. Reference: Sections
59,
129,
3700,
3701.5,
3702.2,
3702.3,
3702.9 and
3702.10, Labor
Code; and Sections
1063.1 and
1063.3,
Insurance Code.
