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Instructions: Private Self Insurer'S Annual Report - 2000 - Department Of Industrial Relations Page 4

determine user funding, fraud and Cal/OSHA targeted inspection assessments (Title 8,

Chapter 8, Sections 15600-15610). If the employment and wage information is not included

on the current annual report form, SIP will use the data from the last annual report form

submitted.

IIA. Administrator

This section must also be completed by the third party administrator, or your in-house claims

administrator if self administered.

A. List the name of the current administrator or TPA at the time the report is being completed.

Note: This may not be the same as the claims administrator actually responsible for

completing the report. If there is a change of administrator on or after January 1, 2000, the

new administrator’s name should be entered in item A, and the name of the prior

administrator completing the annual report should be entered in item C.

List the name of the person responsible for the claims, the administrative agency name and

address, and the complete TPA certificate number that was issued by SIP.

The person named in item A or C must have passed the Administrator’s Exam.

B. Please indicate if there has been any change in claims administration since January 1, 2000.

C. List the name of the prior administrator or administrative agency. Complete this section if

the claims administration changed during the period of the report or since January 1, 2000 as

indicated in item A above.

The certification on one of the reports submitted to SIP must have an original (real, wet)

signature and be completed with the administrator’s name, title, company and address.

A copy of the original signature is not acceptable.

The certification must be signed by a person who works at the reporting office, has passed the

Administrator’s Exam and whose name is on file at SIP. Any claims examiner name change

needs to be reported to SIP prior to submitting the annual reports. A request for a name change

must be accompanied by a copy of documents such as a marriage license, divorce decree or

petition for name change. Reports with unqualified persons signing the liabilities section

will be returned to the self insurer.

Note: All consolidated report pages must be signed. If two different TPAs are administering the

claims of a self insurer, one of the TPAs is required to combine the report on page 2,

Consolidated Liabilities, and must sign that page. One person who qualifies may not sign

annual reports for every adjusting location.

Instructions: Private Self Insurer'S Annual Report - 2000 - Department Of Industrial Relations Page 4