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The prospective new member will fully complete the LAWCX prospective new member application, Form A, and data requirements. Copies of the following documents must be attached with your completed application: |
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Loss History reported per the requirements set forth in the Request for Detail Information – Electronic Data File Submission Workers’ Compensation Claims Information Specifications; |
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Resolution Providing Coverage for Volunteers, if your entity has adopted such a resolution; |
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Most Recent Claims Audit; |
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Most Recent Financial Audit; |
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Most Recent Workers’ Compensation Actuarial Study; |
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“Modified Duty” Policy (if your entity has adopted one); and |
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Agreement and Bylaws (if applicable). |
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If the prospective entity has been accredited by the California Association of Joint Powers Authorities (CAJPA), some requirements of the application may be waived. These requirements have been noted with an asterisk (*) on the application form.
Following receipt of the application, the LAWCX Manager will review the application to ensure all information has been provided. The application and underwriting information will then be submitted to the LAWCX Underwriting Committee for evaluation.
All prospective members, whether applying directly or through an existing LAWCX JPA member, must be approved for membership by the Underwriting Committee prior to binding coverage. After the prospective member has been evaluated and approved for membership, the LAWCX Manager will bind the required coverage. If necessary, the new member’s contribution will be pro-rated from the date of binding of coverage to the end of the program year (June 30th).
Submit the completed application with all requested documentation to the attention of Ms. Jeanette Workman, Manager, at: |
Bickmore Risk Services
Sacramento Office
1831 K Street
Sacramento, CA 95811
Toll Free: (800) 541-4591, ext. 1110
Phone: (916) 244-1110
Fax: (916) 244-1198
E-mail: info@lawcx.org