Get *you Must Submit A Signed Original Which Has Been Sealednotarized* - Wastediversion

Filling out the *YOU MUST SUBMIT A SIGNED ORIGINAL WHICH HAS BEEN SEALED/NOTARIZED* form is an essential step for public entities seeking a certificate of consent to self-insure their workers’ compensation liabilities. This guide will assist you in completing the form accurately and effectively, ensuring that all necessary information is provided.

Follow the steps to complete the online form successfully.

1. Press the ‘Get Form’ button to access the form and open it in your preferred document editor.
2. Begin by filling out the applicant information section. Enter the legal name of the applicant exactly as it is stated on official documents. This ensures accuracy in correspondence and legal matters.
3. Next, provide the street address of the main headquarters. If a different mailing address is applicable, include that as well. This information is critical for communication related to your application.
4. Fill in the federal tax identification number and the city, state, and zip code of your address to ensure proper identification of your entity.
5. Indicate the recipient for correspondence regarding the application. Include their name, title, and the agency's mailing address to guarantee the application is directed appropriately.
6. Select the type of public entity by checking the appropriate box provided in the form. You can choose options such as city, school district, or joint powers authority.
7. Choose the type of application you are submitting by checking either 'New Application' or other specified options if applicable.
8. Specify the date when the self-insurance program will start and document any relevant information regarding current worker's compensation liabilities.
9. Complete sections involving the proposed claims administrator and the number of agency employees, ensuring each entry is accurate.
10. Finally, review all information provided for accuracy and completeness. Once confirmed, save the changes, download the form, and prepare to print it for notarization.
11. After printing, ensure the form is signed by the authorized official and affixed with the agency seal or notarized as required.

Complete your documentation online to ensure a smooth submission process and compliance with all requirements.