Reso 1116-06/2000RESOLUTION NO. 1116
RESOLUTION OF THE BOARD OF DIRECTORS OF THE
VALLECITOS WATER DISTRICT AUTHORIZING APPLICATION
TO THE DIRECTOR OF INDUSTRIAL RELATIONS,
STATE OF CALIFORNIA FOR A CERTIFICATE OF CONSENT
TO SELF -INSURE WORKERS' COMPENSATION LIABILITIES
WHEREAS, the Vallecitos Water District is a public entity organized and existing
under laws of the State of California; and
WHEREAS, pursuant to the provisions of Section 3700 of the California Labor Code,
said Agency may self -insure for Workers' Compensation Liabilities in a joint protection
program; and
WHEREAS, said Agency desires to participate in the ACWA/Joint Powers Insurance
Authority joint protection program for Workers' Compensation coverage.
NOW, THEREFORE BE IT RESOLVED that the Board of Directors of the Vallecitos
Water District authorizes and empowers the General Manager to make application to the
Director of Industrial Relations, State of California, for a Certificate of Consent to Self -
Insure Workers' Compensation Liabilities, and to execute any and all documents required
for such application on behalf of said Agency.
PASSED AND ADOPTED by the Board of Directors of the Vallecitos Water District
at a regular meeting held on this 21st day of June, 2000 by the following roll call vote:
AYES:
NOES:
ABSTAIN:
ABSENT:
DAVY, FERGUSON, HANNAN, MASON, CRUZ
Ra d Cruz, President
B and of Directors
Vallecitos Water District
ATTEST:
William W. Rucker, Secretary
Board of Directors
Vallecitos Water District
STATE OF CALIFORNIA
Resolution No. 1116
Page 1
DEPARTMENT OF INDUSTRIAL RELATIONS
SELF-INSURANCE PLANS
2265 Watt Avenue, Suite 1
Sacramento, CA 95825
Our File: P-
APPLICATION FOR A PUBLIC ENTITY
CERTIFICATE 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 INFORMATLON
Legal Name of Applicant (Show exactly as on Charter or other official documents):
Vallecitos Water District
Street Address of Main Headquarters:
201 Valleditos de Oro
Mailing Address (if different from above):
City, State Zip t 4
San Marcos CA 92069
Federal Tax ID No:
95-6005624
TO WHOM DO YOU WANT CORRESPONDENCE REGARDING THIS APPLICATION ADDRESSED?
Name: Mary D. Clinkscales
Title: Assistant General Manager
Company Name: Vallecitos Water District
Mailing Address: 201 Vallecitos de Oro
City San Marcos State: CA Zip t 4: 92069
Type of Public Entity (Check one):
I_( City and/or County
1_I School District
I_I Police and/or Fire District
I_I Hospital District
I_I Joint Powers Authority
I XI Other: (Describe) County Water District
Type Application (Check One):
LXi New Application -
I_I Reapplication due to Merger or Unification
I_I Reapplication due to Name Change Only
I_I Other (Specify):
Date Self Insurance Program will begin: July 1, 2000
FORM A4-2 (REY. 2-92)
Page 2 Resolution No. 1116
Page 3
Current Program for Workers' Compensation Liabilities
I x I Currently Insured with State Compensation Insurance Fund, Policy Number. 94300662
Policy Expiration Date: Jul v 1. 2000 Yearly Premium. $ 48.352
Current Yearly Incurred (Paid & Unpaid) Lasses: $ 2284 (FY or CY)
II Currently Self -insured: Certificate Number :
Name of Current Certificate Holder:
I_I Other (Describe):
Joint Powers Agreement
Will the applicant be a member of a workers' compensation Joint Powers Agreement for the
purpose of pooling workers' compensation liabilities?
ILL Yes I_I No If yes, then complete the following:
Effective date ofJPA Membership: Jul y 1. 2000JPA Certificate Number: 5807
Name and Title ofJPA Executive Officer:
Daniel K1aff
Name of Joint Powers Agreement Agency:
ACWA/JP IA
Mailing Address of JPA :
5620 Birdcage Street, Suite 200
City: State:
Citrus Heights, CA 95610-7632
Zpt4:
Telephone Number:
/9161 535-7500
PROPOSED CLAIMS ADMINISTRATOR
Who wilt be administering your agency's workers' compensation claims? (Check one:)
I X I JPA will administer, (JPA Certificate No.: 5807
I_I Third party agency will administer, (TPA Certificate No.:
I_I Public entity will self administer.
I I Insurance carrier will administer.
Name of Individual Claims Administrator.
Dianne Salvador
)•
Name of Administrative Agency:
ACWA/JPIA
Mailing Address:
5620 Birdcage Street, Suite 200
City:
State: apt 4:
Citrus Heights, CA 95610-7632
Telephone No.: FAX Number
/916 535-7500 (916965-6847
Page 3 Resolution No. 1116
Page 4
Number of claims reporting locations to be used to handle the agency's claims: 1
Will all agency claims be handled by the administrator listed above? I.1I Yes I_f No
AGENCY EMPLOYMENT
Current Number of Agency Employees: 69
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? IX I Yes k_I No
If answer is 'Nd, explain who is not included and how workers' compensation coverage is to be
provided to the excluded agency employees:
INJURY AND ILLNESS PREVENTION PROGRAM
Does the agency have a written Injury and illness Prevention Program? I X ta Yes I_i No
Name of individual responsible for agency Injury and Illness Prevention Program:
Name and Title:
Paul Freestone, Director of Resources
Company or Agency's Name:
Vallecitos Water District
Mailing Address:
201 Vallecitos de Oro
City:
State: Z1p + 4:
San Marcos CA 92069
Telephone No.:
C 760) 744-0460
SUPPLEMENTAL COVERAGE
Will your self insurance program be supplemented by any insurance or pooled coverage under a
standard workers` compensation insurance policy? l_I Yes I X I No
(If yes, then complete the following):
Name o f Carrier o r Excess Pool:
Policy Number:
Effective Date of Coverage:
Page 4
Resolution No. 1116
Page 5
Will your self insurance program be supplemented by any insurance or pooled coverage under a
specific excess workers' compensation insurance policy? IX 1 Yes I_1 No
(If yes, then complete the following):
Narne of Carrier or Excess Pool: National Union
Policy Number: 415-76-55
Effective Date of Coverage: 7-1-99
Retention Limits: $250,000
Will your self insurance program be supplemented by any insurance or pooled coverage under an
aggregrate excess (stop loss) workers' compensation insurance policy? I_t Yes IX 1 No
(If yes, then complete the following):
Name of Carrier or Excess Pool:
Policy Number:
Effective Data of Coverage:
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 of Authorized Official:
X DW
Typed Name:
William W. Rucker
Title:
General Manager
Agency Name:
Vallecitos Water District
Date:
Seal
(Emboss seal above or Notarize signature)