Form S-3 - California Department of Industrial Relations 2026

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The document is a corporate resolution authorizing a corporation to apply for a Certificate of Consent to Self-Insure Workers' Compensation liabilities in California. It includes details about the meeting where the resolution was adopted and grants authority to corporate officers to execute necessary documents for the application.

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Click ‘Get Form’ to open it in the editor.
Begin by entering the name of your corporation in the designated field at the top of the form. Ensure that this matches your official business registration.
Next, specify the state where your corporation is organized. This is crucial for compliance with state regulations.
Fill in the date of the board meeting where this resolution was adopted. Use the format provided to avoid any errors.
In the resolution section, confirm that your corporation is authorized to apply for a Certificate of Consent to Self-Insure Workers’ Compensation liabilities. You may need to adjust this text if necessary.
Designate a corporate officer who will be responsible for executing documents related to this application. Ensure their name and title are clearly stated.
Finally, have the Secretary of the Corporation sign and date the certificate section at the bottom of the form, confirming its accuracy.

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Versions	Form popularity	Fillable & printable
2016	4.5 Satisfied (24 Votes)
1998	4.5 Satisfied (32 Votes)

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What does the California Department of Industrial Relations do?

DIR administers and enforces laws governing wages, hours and breaks, overtime, retaliation, workplace safety and health, apprenticeship training programs, and medical care and other benefits for injured workers.

What is a CA-1 form used for?

The CA-1 form should be used if you have sustained a traumatic injury on the job. A Traumatic Injury is a wound or other condition of the body caused by external force, including stress or strain.

What is a DWC 1 form in California?

If you are hurt at work, it is imperative that you report your work-related injury or illness, regardless of the nature or severity, to your supervisor immediately. Request an Employees Claim for Workers Compensation Benefits form from your supervisor (its also known as a DWC 1 form).

How to register with California Department of Industrial Relations?

If you have any other questions or need assistance from Cal/OSHA Consultation, please call the toll-free number 1(800) 963-9424 or email us at InfoCons@dir.ca.gov. You may also contact a Cal/OSHA Consultation Service Area Office [dir.ca.gov] near you for more information.

Is a DWC 1 required in California?

If youve been injured on the job in California, your first step toward getting workers compensation benefits is completing and submitting the DWC-1 Claim Form. This form is essential without it, your employer and their insurance company have no legal obligation to provide benefits.

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Who fills out the CA-1 form?

2) Form CA-1 Notice of Traumatic Injury should be completed by the injured employee and the employing agency (EA) supervisor or injury compensation specialist. 3) The CA-1 must be submitted to the EA within 30 days of the date of injury in order for the injured employee to be eligible for Continuation of Pay (COP).

How much is the average workers comp settlement in California?

So, how much are California workers comp settlements? In California, workers compensation settlements vary widely, but most fall between $2,000 and $40,000. About 12% of settlements are under $2,000, 55% range from $2,000 to $20,000, and 13% fall between $20,001 and $40,000.

Form S-3 - California Department of Industrial Relations 2026

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