HomeMy WebLinkAboutRESO 5668.. , .
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• • ORIGINAL
RE80LUTION HO. 5668
RESOLUTIOU OF TIIE COUHi~IL OF THE CITY OF PALO ALTO
AUTHORIZING THE DIRECTOR OF PERSOUUEL TO FILE
APPLICATION FOR A-CERTIFICATE OF CONSENT TO SELF-
lUSURE FOR WORKERS' COMPENSATION
WHEREAS, AB 840, enacted by the Legislature and effective in
1979, requires cities to apply to the Department of Industrial
Relations for consent to self-insure; and
WHEREAS, Section 2.08.205 of the Palo Alto Municipal Code places
responsibility in the Director of Personnel for the City's Workers•
Compensation program; and
WHEREAS, Palo Alto is engaged in a self-insurance program for
its workers' compensation claims;
NOW, THEREFORE, the Council of the City of Palo Alto does
RESOLVE as follows:
SECTIOU 1. The Directo~ of Personnel is authorized to file and
execute all documents necessary to obtain a certificate of consent
to self-insure for workers• compensation.
SECTION 2. The Council finds that this is not a project under
the California Environmental Quality Act and, therefore, no environ-
mental impact asseasment is necessary.
INTRODUCED AND PASSED:. March 19, 1979
AYES:
NOES:
Brenner, Carey, Eyerly9 Fazzino, Fletcher, Henderson, Sher
None
ABSTENTIONS: Hone
APPROVED:
c~? yor
cl t)"Manager
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mvrc:•n<it ,.Ions
• January 1979 · , l fourth Street, Room LLB
Sccromenro Ccliforn:... 9cn1 ~ DEPARTMEl'fTO.,,..lNDUS'TRlALREt.ATlONS ' -~ ~
SELF-INSURANCE PLANS
APPLICATION FOR A CERTIFICATE OF CONSENT
TO SELF-INSURE
(.gr Public £qtitie!&
RHd ~before eotnpleting.
AJI questions lm#i be amwered. If not appliettble use-aymbol N/A.
W«kon'~ Insurance mu.st be maintai:nt:duntil certiru:.ate ill effective.
To the Director of Ind~tliai Relations
The undenigned. an trinployer. hereby applies for a Certificate of Consent to Self-Imme the payineot or
Wmkers·~as Pf'-~-by Section 3700. Labor Code ofCalifomia..
·n. £ollowing info:rm&tion is submitted, ~penalty of perjury. for the purpose of procuring a Certif"acate of Cement
to Self·!mure. which may be given \.'J>O'l proof, satis!ac:tory to the Director of Industrial Relations. ot ability to
le'if·imure acd to pay compensation that may became due to ~ees. -. -
1. OKicial Name of Applicant _ct .... t""'y.__o .... f .... P~a ... l_o_A_l_t_o ________ ~-=c-----------
tSbow-elmCtl7• it ii ill the Cblines' ol ochef"oma.I ~
2. · Pfindpalolfic"addres:s(mch1decounty) ...25!LHam.i.Lton Aye. Palo Alto, CA 94301 Santa Clam
County
3. ~in chatge Qf Sel!Insurance Program _O....,f.._re ... c ..... t .... o .... r_of ......... P .... e .... rs.-o .... n .... n ... e ... l_~---------
4. Type of Public Entity _c ..... h·_ar .... t ... e ... r__...C.a..'ft...iY~--------'-------
.~~ City. Geoenl t..trCity, Special Diauict. eticJ
S. Joint Pooling or Joint Powers Agreem.9nt Yes 0 No ~
Jr a Member provide!
. EffectiveDeteofJPAMembenbip NIA PriortoJPA~ Yes 0 Net 0
JPA Entity Name
NameofJPAMaoager ------------------·----------~~---~------~----~ Teltlpboue--~--------
_Yee 0
Jfyes: Cuneat Yearly Premium (FY) _______ _
1. CurrentYearlylncunedl.oacs (FY).._ .3Q096 (78-'0L Paiil.m Unpaid~
8. Claims Self·Adrnb'listered.? Yea D No []
Ifyes: NameofindividualClaimsAdministrator ----.__.._...:__~------------
Address . ___ Telephone-_----------
9. Claims Agency Administered? Ya I] No 0
lfyes: Name of Agency R. L. Kautz &~.&-.-...,........-__,.~,~:-=~---------
Address of~ncy 100 B.tAsh St. Seo frandsco. CA 94104
Telephone (415) 961-2022
10. Total Number of Employee:-: _....tJZB.,.S-L--_.~--------__;.------------
11. Number of Public Safety Officers ClAI.' enfor-eement, policemen. firemen.*) 204
12. Name olindividu."'l n::;pon.oijbre re.: :Mlf~ti ~nd acd.c:le:-.~ pn~venliOn.
Narnc Oale.L..Jk.eherstm -Tirte .&n.asie.t... l OS$ t.Dntrol
Address 2$.Q Hamil ton Ave. eaJo Al tQ. CA 9g3Ql_ Tekphone_{.fi5} 329;-ZZ, ... 94...__ __ --
.¥fl:l
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AGREEMENT
This appli<:ation is med with the undent.!lnding and the agreement or the applicant herein that a Certificate of
Consent to Self-Insure, if granted, wiU be ~pttKI subject to~ authority of the Director of Indu.trial RelQtiolU to
pt'flCfibe the ru!el! and regulations upon which sairl Ct:rtificate of Consent to Sc1£-Jnsure thail be granted or continued
and $Ubject to the full riellt and authority of the said Director of Industrial Relations to prescribe new and additional
Nies and regulations. It is further agteed th:lt, following revocation or invalidation of said certificate, the: applicant will
pay fees and expenses as provided in the rules and regulations.
I, Ja~ C. Rounds • the uru:lenigned, certilyrmderpenaltyolpeijury. that I en fKXJuaintedwith (l'ril:it or Type)
aft airs of wcl applicant employer to which the nqNeMintatiotu and atattments•t forth in the {oregoinA application,
lllt<lltCl'lment:s, exhibits, Bnd addenda relate: that 1 haw: read Mid applicaiion, attlldu:nenn, exhibits. and~. knaw
content.s tr.ereof and tl;at uid repr~tationa end 6'atemenu therein conWned are true to the beat of~
Ytleclt;e, information. and belief.
i.
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Title·.,...!lirgctor of Personnel
<SEAL OF APPLICANT>*
RESOLUTION
Attach copy(ies) of Cioveming Body'~ Resolution or minutes of the meetinit whereby self-·
inaured status for workers compensation liabilitie5 was eut."iorized and that certaiD penam
(by jDb title) were authorized to net for the Body in this regard.
f,, Arin Tanner
(PriDt cil'l')'pe)
, the tmdenigped Clerk of the said City of Pal o""-'-A-.1_,_to...._ ______ _
. blic entity, hereby certify thet I am the C~ of the ~_public entity, that the foregomg is a full. ~and correct
oftheresolutioaduJypassedbythe City Counc1 l -,tberwfatameetingofsrli.1authoricy
• ~--GowmiJlcBody .
on the day and at the place ~ specified, and that said resofutiol1 hat never been revoked, ~ed. Ot set
e, and is now in full force and effec:i.. . ., . ·
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IN WITNESS WHEREOF, I HAVE SIGNED BY NAME AND AFFIXED THE sEALOF THIS
THis ________ nA1·0F _____ ~_ .... 19
. (SEAL OF APPUCA~ SIGNATURE:
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