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Form: A-2 (1-2016) Page 1

Form: A-2 (1-2016) Page 1-2025

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4.8 out of 5

112 votes

The document is an application form submitted by Monrovia Unified School District to the California Department of Industrial Relations for a Certificate of Consent to Self-Insure workers' compensation liabilities. It includes details about the agency, contact information, current workers' compensation program status, claims administration, and safety programs. The application seeks approval for self-insurance under California Labor Code Section 3700.

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Click ‘Get Form’ to open it in the editor.
Begin by entering the legal name of the applicant exactly as it appears on official documents in the designated field.
Fill in the address fields, including street address, city, state, and zip code. Ensure all information is accurate for processing.
Provide the Federal Tax ID number of the group in the specified section.
Identify a contact person for correspondence by filling out their name, title, company name, address, phone number, and email.
Select the type of public entity by checking the appropriate box. Choose between options like City and/or County or School District.
Indicate whether this is a new application or a reapplication by checking the relevant box.
Complete additional sections regarding current workers' compensation programs and claims administration as required.
Finally, ensure that all fields are filled out completely before signing at the bottom of the form to certify accuracy.

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Versions	Form popularity	Fillable & printable
2016	4.8 Satisfied (112 Votes)

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