HomeMy WebLinkAbout4.10 WorkersCompLiability
CITY CLERK
File # D[1][z][{2]-GV)l
AGENDA STATEMENT
CITY COUNCIL MEETING DATE: September 21, 2004
SUBJECT:
Application to the Director of Industrial Relations, State of
California for a Certificate of Consent to Self Insure Workers'
Compensation Liabilities
Report Prepared by: Julie Carter, Assistant to the City Manager
ATTACHMENTS: 1. Resolution Authorizing Application
2. Application to State of California Department of Industrial
Relations
RECOMMENDATION~ ~ Adcrpt Resolution
FINANCIAL STATEMENT: None
DESCRIPTION: During the Fiscal Year 2004-2005 Budget process the City Manager requested the
City's Personnel Office conduct a study into alternative providers to that of State Compensation Insurance
Fund (State Fund) and the ever rising cost of workers' compensation insurance.
City Staff conducted a comprehensive comparison of four alternatives to State Fund; these included a
small workers' compensation pool through the Association of Bay Area Governments (ABAG), California
Public Entity Insurance Authority (CPEIA), a new start-up public entity pool underdevelopment, and The
Cities Group a local joint powers authority (JPA) established by a group of peninsula cities in 1978.
Annual premium quotations were received from all four alternative vendors. In comparing the proposed
premium rates to that of the State Fund's renewal the savings to the City of Dublin were significant and
ranged from 9% to over 60% in savings to the City for a one-year period.
After considerable research including interviews and review of financial and legal documents, staff
selected The Cities Groups as the preferred alternative to State Fund. The Cities Group presented the most
cost effective proposal to the City of Dublin, City Staff considers the administrator of The Cities Group to
be very knowledgeable and well matched with the City of Dublin's values. The Cities Group
membership currently includes the Cities of Atherton, Foster City, Hillsborough, Half Moon Bay and San
Carlos. One Staffmember from each agency makes up the Board of Directors.
To begin the process of leaving State Fund the City must file an application with the State of California to
consent to self insure for workers' compensation liabilities. This is the first step in a series of events the
City will be undertaking to joint The Cities Group by January 1, 2005.
Staff recommends the City Council adopt the Resolution authorizing the City Manager to make an
application to the Director of Industrial Relations, State of California for a Certificate of Consent to Self
Insure Workers' Compensation Liabilities.
COPIES TO:
1~1
ITEMNO.~
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RESOLUTION NO. - 04
A RESOLUTION OF THE CITY COUNCIL
OF THE CITY OF DUBLIN
*********
AUTHORIZING APPLICATION TO THE DIRECTOR OF INDUSTRIAL RELATIONS, STATE
OF CALIFORNIA FOR A CERTIFICATE OF CONSENT TO SELF INSURE WORKERS'
COMPENSATION LIABILITIES
WHEREAS, the City of Dublin wishes to apply to the Director of Industrial Relations for a
Certificate of Consent to Self Insure workers' compensation liabilities;
NOW, THEREFORE, BE IT RESOLVED that the City Manager is hereby authorized and
empowered to make application to the Director of Industrial Relations, State of California, for a
Certificate of Consent to Self Insure workers' compensation liabilities on behalf of the City of Dublin and
to execute any and all documents required for such application.
PASSED, APPROVED AND ADOPTED this 21 8t day of September, 2004.
AYES:
NOES:
ABSENT:
ABSTAIN:
Mayor
ATTEST:
City Clerk
t::1-.21-0t.f W.,O
Attachment 1
~tsb 1
State of California
Department ofIndustrial Relations
SelfInsurance Plans
2265 Watt Avenue, Suite 1
Sacramento, CA 95825
Phone (916) 483-3392
FAX (916) 483-1535
Our File:
Page 1
APPLICATION FOR A PUBLIC ENTITY
CERTIFICATE OF CONSENT TO SELF INSURE
NOTE: All questions must be answered. Ifnot applicable, enter "N/A".
Workers' compensation insurance must be maintained until certificate is effective.
APPLICANT INFORMATION
Legal Name of Applicant (show exactly as on Charter or other official documents):
Street Address of Main Headquarters;
Mailing Address (if different from above):
Federal Tax ID No.:
City;
State:
Zip + 4:
TO WHOM DO YOU WANT CORRESPONDENCE REGARDING THIS APPLICATION ADDRESSED?
Name:
Title:
Company Name:
Mailing Address:
City:
State:
Zip + 4:
Type of Public Entity (check one):
D City and/or County D School District D Police and/or Fire District D Hospital District D Joint Powers Authority
D Other (describe):
Type of Application (check one):
D New Application D Reapplication due to Merger or Unification
D Reapplication due to Name Change Only
D Other (specify):
Date Self Insurance Program will begin:
Form No. A4-2 (2/92)
ATTACHMENT 2
3lbl
Page 2
CURRENT PROGRAM FOR WORKERS' COMPENSATION LIABILITIES
o Currently Insured with State Compensation Insurance Fund, Policy Number:
Policy Expiration Date:
Yearly Premium: $
Current Yearly Incurred (paid & unpaid) Losses: $
D Currently Self Insured, Certificate Number:
(FY or CY)
Name of Current Certificate Holder:
D Other (describe):
JOINT POWERS AUTHORITY
Will the applicant be a member ofa workers' compensation Joint Powers Authority for the purpose of pooling workers'
compensation liabilities?
DYes D No If yes, then complete the following:
Effective date of JPA Membership:
JPA Certificate No.:
Name and Title of JPA Executive Officer:
Name of Joint Powers Authority Agency:
Mailing Address of JPA:
City:
State:
Zip +4;
Telephone Number: (
PROPOSED CLAIMS ADMINISTRATOR
Who will be administering your agency's workers' compensation claims? (check one)
D JPA will administer, JPA Certificate No.:
D Third party agency will administer, TPA Certificate No.:
D Public entity will self administer D Insurance carrier will administer
Name ofIndividual Claims Administrator:
Name of Administrative Agency:
Mailing Address:
City:
State:
Zip + 4:
Telephone Number; (
)
FAX Number: (
)
%1
Page 3
Number of claims reporting locations to be used to handle the agency's claims:
Will all agency claims be handled by the administmtor listed on previous page?
DYes D No
AGENCY EMPLOYMENT
Current Number of Agency Employees:
Number of Public Safety Officers (law enforcement, police or fire):
If a school district, number of certificated employees:
Will all agency employees be included in this self insurance program? DYes D No
Ifno, explain who is not included and how workers' compensation coverage is to be provided to the excluded
agency employees:
INJURY AND ILLNESS PREVENTION PROGRAM
Does the agency have a written Injury and Illness Prevention Program?
DYes
DNo
Individual responsible for agency Injury and Illness Prevention Progmm:
Name and Title:
Company or Agency Name:
Mailing Address:
City:
State:
Zip + 4:
Telephone Number: ( )
SUPPLEMENTAL COVERAGE
Will your self insurance program be supplemented by any insurance or pooled coverage under a standard
workers' compensation insurance policy? D 0 N
Yes 0
If yes, then complete the following:
Name of Carrier or Excess Pool:
Policy Number:
Effective Date of Covemge:
5,&?
Will your self insurance program be supplemented by any insurance or pooled coverage under a specific excess workers'
compensation insurance policy? DYes D No
If yes, then complete the following:
Name of Carrier or Excess Pool:
Policy Number;
Effective Date of Coverage:
Retention Limits:
Will your self insurance program be supplemented by any insurance or pooled coverage under an aggregate excess (stop loss)
workers' compensation insurance policy? D D
Yes No
If yes. then complete the following:
Name ofCarrÎer or Excess Pool:
Policy Number:
Effective Date of Coverage:
Retention Limits:
RESOLUTION OF GOVERNING BOARD
See Attached Resolution-Page 5
CERTIFICATION
The undersigned on behalf of the applicant hereby applies for a Certificate of Consent to Self Insure the payment of
workers' compensation liabilities pursuant to Labor Code Section 3700. The above information is submitted for the
purpose of procuring said Certificate from the Director of Industrial Relations, State of California. If the Certificate is
issued, the applicant agrees to comply with applicable California statutes and regulations pertaining to the payment of
compensation that may become due to the applicant's employees covered by the Certificate.
Signature of Authorized Official:
Date:
Typed Name:
Seal
Title:
Agency Name:
(Emboss seal above or Notarize signaturc)
lPfJÕ 7
Page 5
RESOLUTION NO.:
DATED:
A RESOLUTION AUTHORIZING APPLICATION
TO THE DIRECTOR OF INDUSTRIAL RELATIONS, STATE OF CALIFORNIA
FOR A CERTIFICATE OF CONSENT TO SELF INSURE
WORKERS' COMPENSATION LIABILITIES
At a meeting ofthe Board of
(enter title)
of the
(enter name of public agency, district)
a
organized and existing under the laws of the State of California,
(enter type of agency)
held on the
was adopted:
day of
. 19_, the following resolution
RESOLVED, that the
(enter position titles)
be and they are hereby severally authorized and empowered to make application to the Director of Industrial
Relations, State of California, for a Certificate of Consent to Self Insure workers' compensation liabilities
on behalf of the
(enter name of district)
and to execute any and all documents required for such application.
I,
. the undersigned
(enter name)
(enter title)
of the Board ofthe said
(enter name of agency)
a
, hereby certify that I am the
(enter type of agency)
(enter title)
of said
, that the foregoing is a full, true and correct copy of the
(enter type of agency)
resolution duly passed by the Board at the meeting of said Board held on the day and at the place therein specified
and that said resolution has never been revoked, rescinded, or set aside and is now in full force and effect.
IN WITNESS WHEREOF: I HAVE SIGNED MY NAME AND AFFIXED THE SEAL OF THIS
Seal
(enter type of agency)
THIS
DAY OF
.19_.
(Signature)
(t$f)f
Model Corporate Resolution
CORPORATE RESOLUTION AUTHORIZING APPLICATION TO
THE DIRECTOR OF INDUSTRIAL RELATIONS, STATE OF CALIFORNIA
FOR A CERTIFICATE OF CONSENT TO SELF INSURE WORKERS' COMPENSATION LIABILITIES
At a meeting of the Board of Directors of
(enter name of corporation)
a corporation organized and existing under the laws of the State of
held on the
day of
19_,
a quorum being present, the following Resolution was adopted:
RESOLVED that the
(enter titles of authorized corporate officers)
be and they are hereby severally authorized and empowered to make application for a Certificate of Consent to Self
Insure to the Department of Industrial Relations of the State of California, and to execute any and all documents
required for such application, including the Instrument of Undertaking in furnishing security.
I,
, the undersigned
Secretary ofthe said
,a corporation,
hereby certify that I am the Secretary of said corporation, that the foregoing is a full, true and correct copy of the
resolution duly passed by the Board of Directors thereof at a meeting of said Board held on the day and at the place
therein specified, and that said resolution has never been revoked, rescinded, or set aside, and is now in full force
and effect.
IN WITNESS WHEREOF: I HAVE HEREUNTO SET MY HAND AND THE CORPORATE SEAL OF SAID
CORPORATION THIS
DAY OF
19_.
(SEAL)
Secretary