NEW MEMBER APPLICATION

The following information is required 
to obtain a quote

  • A completed acord workers compensation application

  • A completed Auto Dealers Compensation of California, Inc. New member application supplement

  • four year's prior loss experience 

UNDER THE TERMS OF THE GROUP SELF-INSURANCE APPROVAL PROCESS ALL PROGRAM APPLICANTS ARE PROVIDED AN INTERIM CERTIFICATE TO JOIN THE AUTO DEALERS COMPENSATION OF CALIFORNIA, INC. CONTINGENT ON THE COMPLETION, EXECUTION AND FILING OF ALL REQUIRED FORMS AND DOCUMENTS.  THE DOCUMENTS AND PAYMENTS REQUIRED FOR MEMBERSHIP ARE AS FOLLOWS:

  1. CERTIFIED AUDITED FINANCIAL STATEMENTS OR REVIEWED FINANCIAL STATEMENTS FOR THE MOST RECENTLY COMPLETED FISCAL PERIOD INCLUDING ALL NOTES AND SCHEDULES.  IF THE FISCAL PERIOD ENDED MORE THAN SIX MONTHS PRIOR TO THE EFFECTIVE DATE OF COVERAGE AN INTERNALLY GENERATED INCOME STATEMENT AND BALANCE SHEET MUST BE PROVIDED.  IT IS A CONDITION OF MEMBERSHIP THAT ALL MEMBERS HAVE ONE OF THESE TYPES OF FINANCIAL  STATEMENTS.  IN THE EVENT THAT THE APPLICANT REQUIRES PREPARATION OF A FINANCIAL STATEMENT THE COST OF PREPARATION WILL BE BORNE BY THE APPLICANT.

  2. A SIGNED JOINDER AND INDEMNIFICATION AGREEMENT PROVIDED BY APPLICANT PRIOR TO BINDING.

  3. THE INITIAL PROGRAM CONTRIBUTION AS OUTLINED ON THE QUOTATION.

  4. EXECUTED RESOLUTION TO BE SELF-INSURED AS A MEMBER OF A GROUP SELF-INSURER.

  5. EXECUTED FORM A-4-8, INDEMNITY AGREEMENT 

  6. SIGNED AFFILIATE APPLICATION FORM.

    NOTE:  ITEMS 4,5, AND 6 WILL BE COMPLETED BY PROGRAM ADMINISTRATOR AND FORWARDED  UNDER SEPARATE COVER AS SOON AS ADMINISTRATIVELY PRACTICAL.

BY SIGNING THIS FORM, THE APPLICANT ACKNOWLEDGES THAT THEY HAVE RECEIVED ALL RELEVANT DOCUMENTS AND AGREES TO PROVIDE ALL SUPPLEMENTAL DOCUMENTS WITHIN THE FIRST 45 DAYS OF MEMBERSHIP.  FURTHER THE APPLICANT CONFIRMS THAT THE INTERIM CERTIFICATE MAY BE TERMINATED FOR FAILURE TO PROVIDE DOCUMENTS AND PAYMENTS AS REQUIRE HEREIN.

PLEASE COMPLETE THE FOLLOWING

LEGAL NAME OF SUBSIDIARY/AFFILIATE (COMPLETE A SEPARATE FORM FOR EACH LEGAL ENTITY ENTERING THE PROGRAM)


STATE OF INCORPORATION :

FEDERAL TAX IDENTIFICATION NUMBER:

REQUESTED EFFECTIVE DATE OF INTERIM CERTIFICATE:

PRINCIPAL CALIFORNIA OFFICE ADDRESS:


THE APPLICANT IS:A CORPORATION  A PARTNERSHIP  other

IF A CORPORATION:
CHARTERED UNDER THE LAWS OF

DATE:

IF A SUBSIDIARY CORPORATION
NAME OF PARENT CORPORATION:

ADDRESS OF PARENT CORPORATION:

PARENT COMPANY'S PERCENTAGE OF STOCK OWNERSHIP

DATE:

IF A PARTNERSHIP

NAME ALL PARTNERS AND DESIGNATE STATUS AS GENERAL, SPECIAL, 
LIMITED, ETC.


WILL NUMBER OF CALIFORNIA EMPLOYEES COVERED UNDER THE PROPOSED MEMBERSHIP BE MATERIALLY INCREASED OR DECREASED IN THE NEXT 12 MONTHS? YES  NO

IF YES, BY HOW MANY?

AT THE DATE OF APPLICATION, IS THERE ANY LITIGATION OR LEGAL PROCEEDING, OR THREATENED, THE RESULT OF WHICH MIGHT SUBSTANTIALLY ADVERSELY AFFECT THE FINANCIAL CONDITION, BUSINESS OPERATIONS OF THE APPLICANT OR ANY OF ITS SUBSIDIARIES?YES  NO

IF YES, EXPLAIN

INDICATE NET PROFIT OR LOSS AFTER TAXES FOR THE LAST FIVE YEARS:

YEAR AMOUNT
2000 $
2001 $
2002 $
2003 $
2004

$

NAME OF APPLICANTS INDIVIDUAL RESPONSIBLE FOR WORKPLACE INJURY AND ILLNESS PREVENTION PROGRAM:

NAME:


TITLE: 


ADDRESS: 


TELEPHONE NUMBER:


PERCENTAGE OF TIME SPENT ON TASK:

HAVING READ AND COMPLETED THE FOREGOING SUPPLEMENTAL APPLICATION, THE APPLICANT HEREBY AGREES THAT THIS DOCUMENT AND ALL SUPPORTING ATTACHMENTS BECOME PART OF APPLICANTS MEMBERSHIP ACKNOWLEDGEMENTS AND FURTHER AGREES THAT THEY WILL SUPPLY ALL SUPPLEMENTAL INFORMATION REQUIRED BY THE PROGRAM ADMINISTRATOR IN A TIMELY FASHION AS REQUIRED HEREIN.

READ AND ACKNOWLEDGED:

LOSS EXPERIENCE  
 ATTACH CLAIMS HISTORY FROM PREVIOUS CARRIER(S) FOR 
PAST FOUR YEARS.  
FAX LOSS EXPERIENCE TO 
(805) 584-6251.

 

FOR ASSISTANCE CALL RANDY FOSTER (800) 936-7837

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