The Office of Self-Insurance Plans (OSIP) has released new application forms for private stand-alone and group insurers as it continues to modernize and simplify steps for employers. The forms were revised to remove unneeded information and language that no longer applies, which significantly reduced the total number of pages required for submission.
The forms can be downloaded for free from the OSIP website and are found under Forms, Publications, and Reports.
Private stand-alone applications:
Form A-1 (1-2016) Application for a Private Entity Certificate of Consent to Self-Insure
Form A-2 (1-2016) Application for a Public Agency Certificate of Consent to Self-Insure
Form A-3A (1-2016) Private Affiliate Interim Application
Form A-3B (1-2016) Application for a Permanent Certificate of Consent to Self-Insure by an Interim Self-Insurer
Form A-4 (1-2016) Guaranty of Workers’ Compensation Liabilities
Form A4-50 Application for a Certificate to Administer Workers’ Compensation Claims
Form A-5 (1-2016) Corporate Resolution Authorizing Application
Form A-6 (1-2016) Agreement and Undertaking for Security Deposit
Form S-1 (1-2016) Group Master Application for Certificate of Consent to Self-insure
Form S-2A (1-2016) Group Affiliate Member Interim Application
Form S-2B (1-2016) Application for Affiliate Certificate of Consent to Self-insure as a Member of a Group Self-insurer
Form S-3 (1-2016) Corporate Resolution
Form S-4 (1-2016) Indemnity Agreement and Power of Attorney
Form S-5 (1-2016) Agreement of Assumption and Guarantee of Workers’ Compensation Liabilities for Group and Affiliate Members
Form S-6 (1-2016) Agreement and Undertaking for Security Deposit
For more information regarding the application forms contact OSIP at (916) 464-7000.
The Office of Self-Insurance Plans (OSIP) is a program within the director’s office of the Department of Industrial Relations (DIR) responsible for the oversight and regulation of workers’ compensation self-insurance within California. OSIP is also responsible for establishing and insuring that required security deposits are posted by self-insurers in amounts sufficient to collateralize against potential defaults by self-insured employers and groups.