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To join this program you will need to complete the
documents listed below, and submit them for approval by the SELF
Board or Executive Committee.
By signing the SELF JPA Agreement, you agree to stay with the
program for a minimum of three years.
Membership approval can be backdated up to 30 days prior to the
date the completed documents are received by the SELF office.
The Board or Executive Committee meet monthly. You can check for
the next meeting by checking the SELF
Meetings section.
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| Application Documents to Complete: |
| 1. An Excess Workers' Compensation
Application Form. |
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Application
for Excess Workers' Compensation Coverage MS Excel mail-in form
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| and an Employee Concentration Report |
Once the application is completed, please fax (916-321-5311)
or mail the form to the SELF office (1531 I Street, Suite 300,
Sacramento, CA 95814).
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Once approved by the underwriter, the applicant
will then need to submit:
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| 2. A signed JPA
Agreement |
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| 3. Board Resolution to join SELF |
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Workers'
Compensation Resolution |
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| 4. Third Party Administrator Questionnaire
Form |
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TPA
Questionnaire Form |
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| Once the application is approved, we will send you
a Members' Manual along with the invoice. You will have 60 days
to submit payment. |
