DIVISION OF WORKERS' COMPENSATION
SUPPLEMENTARY APPLICATION
UNDER LABOR CODE SECTION 4600.6.
Date of Application:
WORKERS' COMPENSATION HEALTH CARE PROVIDER
ORGANIZATION AUTHORIZATION APPLICATION
LABOR CODE SECTION 4600.6 (EXECUTION PAGE)
Identification of Organization.
Name of Applicant.
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Exhibit numbers being amended
Additional Exhibits: An original application for organization authorization must include the completed form specified in this subsection and the exhibits required.
If the appropriate response to this item is "yes," attach as Exhibit D-3 a statement identifying each such person or entity and explaining fully such person's power or control, and summarizing every contract or other arrangement or understanding (if any) with each such person. (Each such contract should be submitted pursuant to Subsection D-2.)
If "yes," attach a separate exhibit as to each such person designated Exhibit D-4, identifying such person and fully explaining the crime or act committed. Also, attach a copy of the exhibit to any Individual Information Sheet required by Item D-1-e for such individual.
Section | 4600.6(g) | |||
4600.6(I)(8) | ||||
4600.6(n) | ||||
Rules | 9771.69 | |||
9771.70 | ||||
9772 through 9778 |
Compliance with Requirements. Attach as Exhibit F a schedule in tabular form for each workers' compensation health care contract and each standard form workers' compensation contract, identifying the particular provision of such contract which complies with the sections listed below, covering also any variations made in standard form contracts. As to any provision which varies from the applicable provision of the Act or rules, identify such provision in Exhibit F.
Section | 4600.5(e)(7)(B) | |||
4600.6(e) | ||||
Rules | 9771.67 | |||
9771.69 | ||||
9772 - 9778 |
Attach as Exhibit G a copy of any advertising which is subject to Section 4600.6 of the Code and which applicant proposes to use. With respect to each proposed advertisement indicate the contract(s) by name and by exhibit number(s) to which such advertisement relates and identify the employer segment to which the advertisement is directed.
Attach as Exhibit H a statement describing the methods by which applicant proposes to market workers' compensation health care contracts, including the use of employees, or contracting solicitors or solicitor firms, their method or form of compensation, and the methods by which applicant will obtain compliance with Rules 9771.64, 9771.65, and 9771.83.
Attach as Exhibit I a statement setting forth applicant's internal arrangements to supervise the marketing of its workers' compensation health care contracts, including the name and title of each person who has primary management responsibility for the employment and qualification of solicitors, advertising, contracts with solicitors and solicitor firms and for monitoring and supervising compliance with contractual and regulatory provisions.
NOTE: All projections are to cover the period commencing from the applicant's commencement of operations as an authorized and certified workers' compensation health care provider organization for two years.
STATE OF CALIFORNIA
DIVISION OF WORKERS' COMPENSATION
D-1-a-iii CORPORATION
INFORMATION FORM
To be used in response to Item D-1-a of Form WCHCPO 1.
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Full Name Last First Middle | Relationship Beginning Date Mo. Year | Class of Equity Title or Security Status | Percent of Class | |
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STATE OF CALIFORNIA
DIVISION OF WORKERS' COMPENSATION
EXHIBIT D-1-ii PARTNERSHIP
INFORMATION FORM
To be used in response to Item D-1-b of Form WCHCPO 1.
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Full Name Last First Middle | Beginning Date Mo. Year | Type of Partner | Capital Contribution (percentage) | Title or Duties | |
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STATE OF CALIFORNIA
DIVISION OF WORKERS' COMPENSATION
EXHIBIT D-1-c SOLE PROPRIETORSHIP
INFORMATION FORM
To be used in response to Item D-1-c of Form WCHCPO 1.
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Full Name Last First Middle | Beginning Date Mo. Year | Title and Duties | |
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STATE OF CALIFORNIA
DIVISION OF WORKERS' COMPENSATION
EXHIBIT D-1-d INFORMATION FORM FOR MISCELLANEOUS TYPES OF ENTITIES.
To be used in response to Item D-1-d of Form WCHCPO 1.
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Full Name Last First | Beginning Date Mo. Year | Class of Equity Security | Percent of Class | Title and Duties | |
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Cal. Code Regs. Tit. 8, § 9771.62
Note: Authority cited: Stats. 1997, Ch. 346 Section 5. Reference: Sections 4600.3, 4500.5 and 4600.6, Labor Code.