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Home My WebLink About18-91 �. • 411 • • • RESOLUTION NO: 18-91 DATED: May 15, 1991 A RESOLUTION AUTHORIZING APPLICATION TO THE DIRECTOR OF INDUSTRIAL RELATIONS, STATE OF CALIFORNIA FOR A CERTIFICATE OF CONSENT TO SELF INSURE WORKERS COMPENSATION LIABILITIES At a meeting of the City Council of the Town of Los Altos Hills, a municipal corporation organized and existing under the laws of the State of California, held on the 15th day of May, 1991, the following resolution was adopted: RESOLVED, that the City Manager and/or the Financial Officer be and they are hereby severally authorized and empowered to make application to the Director of Industrial Relations, State of California, a Certificate of Consent to Self Insure workers ' compensation liabilities on behalf of the Town of Los Altos Hills and to execute any and all documents required for such application. I, Patricia Dowd, the undersigned City Clerk of the Town of Los Altos Hills, a municipal corporation, hereby certify that I am the City Clerk of said municipal corporation, that the foregoing is a full, true and correct copy of the resolution duly passed by the City Council at the meeting of said City Council held on the day and at the place therein specified and that said resolution has never been revoked, rescinded, or set aside and is now in full force and effect. IN WITNESS WHEREOF: I HAVE SIGNED MY NAME AND AFFIXED THE SEAL OF THIS MUNICIPAL CORPORATION, THIS 16th DAY OF May , 1991. (Seal of Applicant) _ •• Patricia Dow. , City Clerk PB\MAS\1494906Y.W50 .. � • • I I . STATE OF CALIFORNIA Page 1 DEPARTMENT OF INDUSTRIAL RELATIONS tj►'a SELF-INSURANCE PLANS Our File: P- 2848 Lss , Arden Way, Suite 105 -r Sacramento, CA 95825 APPLICATION FOR A PUBLIC ENTITY CERTIFICATE OF CONSENT TO SELF INSURE NOTE: All questions must be answered. If not applicable, use symbol "N/A". Workers' compensation insurance must be maintained until certificate is effective. APPLICANT.INFORMATION Legal Name of Applicant (Show exactly as on Charter or other official documents): Town of Los Altos Hills Street Address of Main Headquarters: 26379 Fremont Road Federal Tax ID No: Mailing Address (if different from above): 94-6027523 City, State Zip + 4 Los Altos Hills, CA 94022 Type of Public Entity (Check one): J City and/or County I_J School District I I Police and/or Fire District IJ Hospital District I I Other: (Describe) Type Application (Check One): M New Application I I Reapplication due to Merger or Unification IJ Reapplication due to Name Change Only LI Other (Specify): Current Program for Workers' Compensation Liabilities rx, Currently Insured with State Compensation Insurance Fund, Policy Number: 212274 Policy Expiration Date: 6/30/91 Yearly Premium: $ 3 988 Current Yearly Incurred (Paid & Unpaid) Losses: $ 430 (FY or CY) I I Currently Self- Insured: Certificate Number : Name of Current Certificate Holder: I_I Other (Describe): _ • � • i Page 2 Joint Powers Agreement Will the applicant be a member of a workers' compensation Joint Powers Agreement? Yes I I No If yes, then complete the following: Effective date of JPA Membership: 7/1/91 JPA Certificate Number : JPA 2139 Name and Tide of JPA Executive Officer: Revan A. F. Tranter, President Name of Joint Powers Agreement Agency: A3AG Comp Pool Insurance Authority Mailing Address of JPA : P. 0. Box 2089 City State Zip + 4 nakl and CA 94604-2039 Telephone Number: (415) 464-7952 PROPOSED CLAIMS ADMINISTRATOR Who will be administering your agency's workers' compensation claims? (Check one:) I JPA will administer, (JPA Certificate No.: ). (XI Third party agency will administer, (TPA Certificate No.: 0.124 ) I I Public entity will self administer. IJ Insurance carrier will administer. Name of Individual Claims Administrator: Alexis Rankin Popik Name of Administrative Agency: Association of Bay Area Governments Mailing Address: P. 0. Box 2089 City: State: Zip + 4: Oakland, CA 94604-2089 Telephone No.: FAX Number: (415) 464•-7952 ( 415) 464-7979 Number of claims reporting locations to be used to handle the agency's claims: Will all agency claims be handled by the administrator listed above? Ix I Yes I I No • a • Page 3 AGENCY EMPLOYMENT Current Number of Agency Employees: 15 Number of Public Safety Officers (law enforcement, police or fire): 0 If a school district, number of certificated employees: N A Will all agency employees be included in this self insurance program? LJ Yes I I No If answer is 'No', explain who is not included and how workers' compensation coverage is to be provided to the excluded agency employees: SAFETY AND ACCIDENT PREVENTION Does the agency have a written Safety and Accident Prevention Program? I XI Yes IJ No Name of Individual responsible for agency Safety and Accident Prevention Program: Name and Title: William Ekern, Director of Public Works Company or Agency's Name: Town of Los Altos Hills Mailing Address: 26379 Fremont Road. City: State: Zip+ 4: Los Altos Hills CA 94022 Telephone No.: ( 415 941-7222 SUPPLEMENTAL INSURANCE Will your self insurance program be supplemented by any insurance coverage under a standard workers' compensation insurance policy? I I Yes I I No (If yes, then complete the following): Name of Carrier: Policy Number: Policy Issue Date: ..f• 0 • • ; , •_ Page 4 Will your self insurance program be supplemented by any insurance coverage under a specific excess workers' compensation, insurance policy? pc 1 Yes 1 1 No (If yes, then complete the following): Name of Carrier: National Union Fire Insurance Policy Number: 415--2.298 Policy Issue Date: 10/1/80 - renews annually Retention Limits: $250 , 000 (coverage : $10 million per occurrence) Will your self insurance program be supplemented by any insurance coverage under a aggregrate excess (stop loss)--workers' compensation insurance policy? Yes I x1 No (If yes, then complete the following): Name of Carrier: Policy Number: Policy Issue Date: Retention Limits: RESOLUTION OF GOVERNING BOARD See Attached Resolution CERTIFICATION The undersigned on behalf of the applicant hereby applies for a Certificate of Consent to Self insure the payment of workers' compensation liabilities pursuant to Labor Code Section 3700. The above Information is submitted for the purpose of procuring said Certificate from the Director of industrial Relations, State of California. If the Certificate Is issued, the applicant agrees to comply with applicable California statutes and regulations pertaining to the payment of compensation that may become due to the applicant's employees covered by the •Certificate. Signature oJiAut - i ed Offic% • Date: /S-)7 41/9•91 • •-d Name: Louise Parmett Title: Treasurer Agency Name: Town of Los Altos Hills (Emboss seal above)