Part 3, Group Workers’ Compensation Insurance, of the Miscellaneous Regulations for Recording and Reporting of Data—1995 (Miscellaneous Regulations) provides that an insurer may insure an organization or association of employers as a group pursuant to the provisions of Sections 11656.5, 11656.6 and 11656.7 of the California Insurance Code if such organization or association files with the WCIRB certain documents, statements and agreements.

Provided below are forms that can be used by the insurer and template letters that can be used by the group when submitting original and renewal group requests. (See Part 3, Section II, Procedure for Obtaining Approval of Group Workers’ Compensation Insurance of the Miscellaneous Regulations for further information.) Please note that the documents, statements and agreements must be filed at least thirty (30) days prior to the effective date of the proposed group policy. Renewal filings are due once every five years.

Original Group Requests

• Form 603 – Request for Approval of Group Insurance
• Template – Association’s Original Request for Group Insurance

Renewal Group Requests

• Form 604 – Request for Renewal of Group Insurance
• Template – Association’s Renewal Request for Group Insurance

Related Information

• Miscellaneous Regulations for Recording and Reporting of Data—1995