Cal. Code Regs. tit. 10 § 2699.6121

Current through Register 2024 Notice Reg. No. 45, November 8, 2024

Section 2699.6121 - Application for Sole Employers

(a) To apply for the program a sole employer shall submit:

(1) All information, documentation, and declarations necessary to determine program qualification and employee eligibility as set forth in subsection (d) of this section, and

(2) The name, position, and phone number of a designated contact person, and

(3) One check or money order for an amount equal to the initial one month employer premium. If the check is returned for non-sufficient funds, the application shall be considered incomplete.

(b) The sole employer shall designate a person legally authorized to sign and date required declarations on behalf of the sole employer stating that the information given is accurate and complete to the best of their knowledge.

(c) An incomplete application shall not be processed and may be returned to the sole employer.

(d)

(1) The application shall contain the following:

(A) The sole employer's complete name.

(B) The sole employer's current business address including unit number, street, city, county, state, and zip code.

(C) The address to which the bills for the sole employer's premiums are to be sent, if different from (B).

(D) The sole employer's federal tax identification number.

(E) The sole employer's telephone number.

(F) The industry type of the sole employer.

(G) A copy of the sole employer's most recent state Employment Development Department's (EDD) Form DE6 (entitled "Quarterly Wage Report") Form DE 3B (entitled "Report of Wages") or Form DE 3DP (entitled "Quarterly Contribution Report") as submitted to EDD and a copy of the Federal W-4 form or employer payroll records for any employee not listed on the EDD forms submitted to the program.

(H) The name and address of the sole employer's worker's compensation carrier, and the policy number.

(I) The number of eligible employees, or employees who will be eligible by the effective date of coverage, employed by the sole employer and the number of eligible employees, or employees who will be eligible by the effective date of coverage, applying for enrollment in the program.

(J) A notification to the program of persons, if any, who can be demonstrated to have legal access to replacement coverage pursuant to California Insurance Code Section 10128.3 or California Health and Safety Code Section 1399.63.

(K) A declaration that the sole employer has informed every potential sole employee of the opportunity to obtain coverage from the participating carriers in the program and that each potential sole employee was given at least thirty (30) calendar days to respond to the opportunity.

(L) A declaration that the sole employer will inform and invite potential sole employees to respond in a consistent time and manner.

(M) A declaration that 100% of the eligible employees enrolling in the program legally required to be covered by workers' compensation insurance are so covered.

(N) A declaration that each of the employees applying for enrollment in the program is an eligible employee or will be an eligible employee by the effective date of coverage.

(O)

(1) For sole employers who have an effective date of coverage prior to September 1, 1998, who have not made an election pursuant to Section 2699.6116, a declaration that the employer will contribute an amount equal to at least 50% of the lowest available employee only rate for each applying employee. If the sole employer will contribute 100% of the employee only rate, the declaration must so state.

(2) For sole employers who have an effective date of coverage on or after September 1, 1998, or who have made an election pursuant to Section 2699.6116, a declaration that the employer will contribute an amount equal to at least 50% of the lowest available employee only comprehensive individual medical premium for each applying employee. If the sole employer will contribute 100% of the employee only comprehensive individual medical premium, the declaration must so state.

(P) For sole employees with four (4) or more eligible employees, a declaration that at least 70% of the eligible employees, or employees who will be eligible as of the effective date of coverage, are applying for enrollment in the program. If the sole employer contributes 100% of the "employee only" rate or the "employee only" comprehensive individual medical premium or if the sole employer has two (2) or three (3) eligible employees, a declaration that 100% of employees who will be eligible employees as of the effective date of coverage, are applying for enrollment.

(Q) A declaration that the sole employer will abide by the rules of participation and premium payment requirements of the program.

(R) A declaration that those eligible employees who have declined coverage in the program for themselves or for any of their dependents have signed a form explaining to them that they will be unable to enroll in the program until the program's next open enrollment period.

(S) A declaration by a legally authorized representative of the sole employer stating that the information is accurate and complete to the best of their knowledge.

(T)

(1) For sole employers who have an effective date of coverage prior to September 1, 1998 who have not made an election pursuant to Section 2699.6116, either the agent/broker payment request specified in Section 2699.6194(a)(1) or the sole employer certification specified in Section 2699.6194(a)(2).

(2) For sole employers who have an effective date of coverage on or after September 1, 1998 or who have made an election pursuant to Section 2699.6116, the agent/broker payment request specified in Section 2699.6194(b)(2).

(2) The sole employer shall submit information for each eligible employee who is applying for enrollment that includes the following:

(A) The employee's full name.

(B) The employee's current residence address including house or unit number, street, city, county, state, and zip code.

(C) The employee's home and work phone numbers.

(D) The employee's date of birth.

(E) The employee's sex.

(F) The employee's social security number, as defined in Section 2699.6000.

(G) The employee's medical insurance information, including the carrier name and address of:

1. Any current medical insurance or other health benefits including coverage under the federal Medicare program pursuant to Title XVIII,

2. Most recent prior medical insurance or other health benefits.

(H) The employee's date of employment with the sole employer, the number of hours in the employee's normal workweek, and the date, if different from the employment date, that the employee began a normal workweek of at least thirty (30) hours.

(I) If dependents are to be included in the coverage, the full names, dates of birth, sex, social security numbers as defined in Section 2699.6000, if available, relationship of the dependents to be covered and medical insurance information for each dependent as specified in (G) above.

(J) The participating carrier and health benefits plan that the eligible employee is selecting for coverage.

(K) A signed and dated declaration by the eligible employee that declares the following:

1. The employee will follow the rules and regulations of the program.

2. The employee has reviewed the services and coverage offered by the participating carriers and the premium rates of the participating carriers.

3. The employee resides in the service area of his/her selected participating carrier.

4. The employee will abide by the rules, utilization review process, and dispute resolution process of the participating carrier which the eligible employee has selected.

5. The employee understands that he or she meets the program requirements to be an eligible employee.

6. The information given is true and correct.

Cal. Code Regs. Tit. 10, § 2699.6121

1. Renumbering and amendment of former section 2699.623 to section 2699.6121 filed 5-27-94; operative 5-27-94 (Register 94, No. 21).
2. Amendment of subsections (d)(1)(I), (d)(1)(M) and (d)(1)(O) filed 12-29-94 as an emergency; operative 12-29-94 (Register 94, No. 52). A Certificate of Compliance must be transmitted to OAL 4-28-95 or emergency language will be repealed by operation of law on the following day.
3. Change without regulatory effect amending subsection (d)(1)(G) filed 5-5-95 pursuant to section 100, title 1, California Code of Regulations (Register 95, No. 18).
4. Certificate of Compliance as to 12-29-94 order including amendment of subsection (d)(1)(O) transmitted to OAL 4-12-95 and filed 5-22-95 (Register 95, No. 21).
5. Amendment of subsections (d)(1)(G), new subsection (d)(1)(J), subsection relettering, and amendment of newly designated subsection (d)(1)(P) filed 6-16-95 as an emergency; operative 6-16-95 (Register 95, No. 24). A Certificate of Compliance must be transmitted to OAL by 10-16-95 or emergency language will be repealed by operation of law on the following day.
6. Certificate of Compliance as to 6-16-95 order transmitted to OAL 9-26-95 and filed 10-18-95 (Register 95, No. 42).
7. Amendment of subsection (d)(1)(P) filed 5-5-97; operative 7-1-97 (Register 97, No. 19).
8. Redesignation and amendment of former subsection (d)(1)(O) to new subsection (d)(1)(O)(1), new subsection (d)(1)(O)(2), amendment of subsection (d)(1)(P), redesignation and amendment of former subsection (d)(1)(T) to new subsection (d)(1)(T)(1) and new subsection (d)(1)(T)(2) filed 7-3-98 as an emergency; operative 7-3-98 (Register 98, No. 27). A Certificate of Compliance must be transmitted to OAL by 11-2-98 or emergency language will be repealed by operation of law on the following day.
9. Certificate of Compliance as to 7-3-98 order transmitted to OAL 10-2-98 and filed 11-16-98 (Register 98, No. 47).

Note: Authority cited: Section 10731, Insurance Code. Reference: Section 10731, Insurance Code.