Resolution 2561
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RESOLUTION NO. 2561
A RESOLUTION OF THE BOARD OF DIRECTORS OF THE SOUTH TAHOE
PUBLIC UTILITY DISTRICT AUTHORIZING APPLICATION TO THE
DIRECTOR OF INDUSTRIAL RELATIONS, STATE OF CALIFORNIA FOR
A CERTIFICATE OF CONSENT TO
SELF-INSURE WORKERS COMPENSATION LIABILITIES
BE IT RESOLVED, by the Board of Directors of the South
Tahoe Public Utility District, County of El Dorado, State of
California, organized and existing under the laws of the State of
California, as follows:
9 authorized and empowered to make application to the Director of
That the Board of Directors are hereby severally
10 Industrial Relations, State of California, a Certificate of
11 Consent to Self Insure workers' compensation liabilities in
12 behalf of the South Tahoe Public Utility District and to execute
13 any and all documents required for such application.
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14 PASSED AND ADOPTED at a duly held regular meeting of
15 the Board of Directors of the South Tahoe Public Utility District
J6 on the 7th day of May, 1992, by the following vote:
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AYES: Wallace, Onysko, Pierini, Mosbacher, Mason
NOES:
ABSTAIN:
ABSENT:
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LOU PIERINI, CHAIRMAN OF THE BOARD
SOUTH TAHOE PUBLIC UTILITY DISTRICT
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ATTEST: . fAr- (..I '2-~.d
PAT A. ~mMATH, CLERK OF THE BOARD
SOUTH TAHOE PUBLIC UTILITY DISTRICT
Sl),TE: OF CALIFORNIA
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DEPARTMENT OF INDUSTRIAL RELATIONS
SELF-INSURANCE PLANS
{;48 Arden Way, Suite 105
"ramenta, CA 95825
Our File: P-
@
APPLICATION FOR A PUBLIC ENTITY
CERTIFICATE OF CONSENT TO SELF INSURE
NOTE: All questions must be answered. If not applicabfe, use symbol-NlN.
Workers' compensation insurance must be maintained until certifICate is effective.
APPLICANT INFORMATION South Tahoe Public Utility District
Legal Name of Applicant . (Show exactly as on Charter or other offICIal documents):
1275 Meadow Crest
Street Address of Main Headquarters:
P.O. Box 19487
Mailing Address (if different from above):
Federal Tax ID No:
South Lake Tahoe,
City,
CA
State
96151
L1p+4
94-1337-914
\..,p., of Public Entity (Check one):
U City and/or County
U School District
U Police and/or Fire District
U Hospital District
L19 Other. (Describe) Utili ty District
Type Application (Check One):
LXI New Application
U Reapplication due to Merger or UnifICation
U Reapplication due to Name Change Only
U Other (Specify):
Current Program for Workers' Compensation LIabilities
Group Number 076
LXJ Currently Insured with State Compensation Insurance Fund, Policy Number: 000 lJ J lJ - ~ 1.
Policy Expiration Date: 7/1/92 Yearly Premium: $ 148.172
Current Yearly Incurred (Paid & Unpaid) Losses: $ l) 7 ,41 0 (FY or CY)
1--1 Currently Self- Insured:
Certificate Number :
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Name of Current Certificate Holder:
I_I Othor (Describe):
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AGENCY EMPLOYMENT
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Current Number of Agency Employees:
] 00
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? l1U Yes UNo
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? ug Yes LJ No
Name of Individual responsible for agency Safety and Accident Prevention Program:
- Name and Title:
.J
Nancy Hussmann. Human Resourcp.s nirp.r.ror
Company or Agency's Name:
South Tahoe Public Utility nisrrir.r
Mailing Address:
P.O. Box 19487
City:
State:
Zip + 4:
South Lake Tahoe
Telephone No.:
(916) 54J.l-6474
CA
96151
SUPPLEMENTAL INSURANCE
Will your self insurance program be supplemented by any insurance coverage under a
standard workers' compensation insurance policy? U Yes LKJ No
(If yes, then complete the fo/fowing):
Name of Carrier:
Policy Number:
Policy Issue Date:
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\..,~olnt Pow.r. Agr..ment
Will 1he apprlCant be a member of . woriters' compensation Joint Powers Agreement?
t!J - Yes U No H yes, then compl#l,e lluI following:
EtkK:tive date 01 JPA 1Mmbersh1p:
3-20-86
JPA c.rI1f1cllte Number: 2221
HarM and ntlfl of JPA ExtICutJw OffICer:
ROnald Tsugita, President
HarM of Joint Powel$ Agl'fHIfMnt ASlfIncy;
California Sanitation Risk Management Authority
Ual/ing Add,e" of JPA :
Public Entity Group, P:O. Box 7601
tAste ~fi~~-7 601
c/o Sedgwick James,
City .
San FranC1SCO
Tele~o. M Number.
14' 983-9633
\." PRbPOSEO CLAIMS 'ADMINISTRATOR
Who win be administering your agency's wof1(ers' compensation claims? (Check one:)
U JPA win administer, (JPA Certificate No.: ).
LxJ Third party agency wlll administer, (TPA Certificate No.: 0132 ).
U Public entity will self admInister.
U Insurance carrier will administer.
Hams of Individual Claims Administrator:
R~lph W Matthews
NatM of AdmlnlstriJ.tlve AtJency:
Gregory B. Bragg & Associates, Inc.
MaUlng AddrlJ$s:
P.O. Box 41528
City:
Sacramento, CA
T lJlephone No.:
(916 )344-7995
State:
ZfJ + 4:
95841
( ~t[lN~~~932
~ Number of claims reponing locations to be used to handle the agency's claims:
Will all agency claims be handled by the administrator listed above? lXJ Yes U No
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\.cENCY EMPLOYMENT
Current Number of Agency Employees: 100
Number of Public Safety Officers (law enforcement, police or fire): 0
If a school district. number of certifICated employees: n/ a
Will all agency erTll10yees be Included in this self Insurance program? lXJ Yes U 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? LKI Yes LJ No
Name of Individual responsible for agency Safety and Accident Prevention Program:
\r
4 Name and Title:
Nancy Hussmann. Human Resour~es nirp~tor
Company or Agency's Name:
South Tahoe Public Utiljty Distri~t
Mailing Address:
P.O. Box 19487
City:
State:
Zip + 4:
South Lake Tahoe
Telephone No.:
(.H6) 54.4-6474
CA
96151
SUPPLEMENTAL INSURANCE
Will your self insurance program be supplemented by any insurance coverage under a
standard workers' compensation insurance policy? U Yes lXJ No
(If yes, then complete the following):
Name of Carrier:
~
Policy Number:
Policy Issue Date:
, . MAY 08 '92 09:23 SEDGWICK JAMES- S.F.
P.i
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Will your self Insurance program be supplemented by any insurance coyerage under ·
specifIC excess workers' compensation Insurance policy? W Yes UNo
(It y.s, then cornp16t. the tollowlng):
Name ot Carrier: Employers Rei nsurance Corp.
Polley Number:
C-22743-Q
Po/~y "sue Date: 7-1-90
R.t~mtion Limits: $200,000. each accideAt and for each employee disease
WIU your ..tf insurance program be supplemented by any Insurance coverage under a
aggregrate eXCG$$ (stop Joss) workers' CO(1l)8naation Insurance poUcy? LJ Yes ~ No
(If r-s, then complflt. 1M following):
Name of Carrier:
Policy Number:
Policy IssU4t Oat.:
Retenrlon Limits:
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RESOLUTION OF GOVERNING BOARD
SH Attacfuld Resolution
CERTIF1CA TION
The und.ralgned on b.half of the applicant h....by appU.. for a Certificate of
Con..nt to Self Inlure the payment of worke,..' compen..Uon U,bUttl.. pursuant
to labor Cod. Sectlon 3700. The ,bove InformaUon Is .ubmltted for the purpose
of procurIng uld Certificate from the Director of Induatrlal Relation., State of
Camornl.. If the Certificate la IlIued, the appltcant agre.. to comply with
applteable California atatute. and regulation. pertaining to the payment of
compen.aUon that m.)' become due to the appncant'. employ... covered by the
Certificate.
Signature of AuthorizfHJ OfflCla/:
Date:
x ~:I- x6&-
TYi>>d N~ms: !'
Robert G. Baer
Title:
General Manager
'-' Agency Name:
South Tahoe Public Utility District
May 8, 1992
(Emboss seal above)