Form A4-40 - Private Self Insurer'S Annual Report - 2000
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12NOTE: Self Insured Employer
Page 1
NOTE:
Complete this page on ALL reports.
Year Ending December 31, 2000
State of California
Department of Industrial Relations
Self Insurance Plans
2265 Watt Avenue, Suite 1
Sacramento, CA 95825
Web site
E-mail: sip@dir.ca.gov
PRIVATE SELF INSURER’S ANNUAL REPORT
I. GENERAL
1. CERTIFICATE NUMBER:
2. PERIOD OF REPORT:
Full Year
Interim Report for the Period of:
Active
Revoked
Month
Day
Year
to
Month
Day
Year
3. NAME OF MASTER CERTIFICATE HOLDER:
State of Incorporation:
NAME
Federal Tax Identification No.:
ADDRESS
First 4 Digits of Your Standard
CITY
STATE
ZIP + 4
Industrial Classification (SIC) Code:
4. List names of ALL separate, but affiliated or subsidiary companies covered by this certificate
4.
(do not include DBAs or operating divisions):
STATE OF
SUBSIDIARY/AFFILIATE
FULL LEGAL NAME
INCORPORATION
CERTIFICATE NUMBER
(Continue on reverse side of this page if necessary.)
5. During the reporting period of this report, has there been any of the following
5.
with respect to the Master Certificate Holder or any subsidiary?
(a) Reincorporating
Yes
No
(b) Merger
Yes
No
(c) Change in Identity
Yes
No
(d) Any additions to Self Insurance Program
Yes
No
6.
If yes, explain:
(Continue on reverse side of this page if necessary.)
6. TO WHOM DO YOU WANT CORRESPONDENCE ADDRESSED?
NAME/TITLE:
COMPANY NAME:
ADDRESS:
CITY:
STATE:
ZIP+4:
TELEPHONE: (
)
FACSIMILE (FAX) NUMBER: (
)
E-MAIL ADDRESS:
SUBMIT TWO (2) COMPLETE REPORTS OF PAGES 1 THROUGH 6, INCLUDING:
• LIST OF OPEN INDEMNITY CLAIMS
• SPECIFIC EXCESS INSURANCE POLICY COVERAGE PAGE
REPORT IS DUE MARCH 1, 2001
Form A4-40a (4/92)
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