Fillable Printable De 2778

De 2778

DE 2778 (3-11) (INTERNET) Page 1 of 4 CU

SMALL-BUSINESS THI RD-PARTY ADMINISTRATOR

VOLUNT ARY PL AN APPLI CATION PURSUANT TO AB 2778

1. Effective date of this voluntary plan:

SMALL- BUSINESS THIRD-PARTY ADMINISTRATOR (SBTPA) INFORMATION

2. SBTPA Commercial Nam e:

Address:

City, State, Zip Code:

Telephone Number:

( )

3. SBTPA California Employer Account Number (EAN): (this is the 8-digit number that

the Employment Development Department (EDD) assigned when the company registered with

DD as a California employer).

SBTPA QUALIFICATIONS

4. T

he written terms and provisions of the SBTPA Self-Insured Voluntary Plan (SIVP) Document/Text

must be approved by the Director of the EDD.

5. T

he SBTPA must maintain at least 1,000 California domiciled clients, 80 percent of whom hav

ewer than 20 employees. A current list of the company’s California clients listing the legal names

(include aka and dba names), 8-digit California EAN, complete address, phone number, number of

employees, and FAX and e-mail addresses (if available) must be attached to this application.

6. T

he SBTPA must process payroll for its California domiciled clients. Client payroll will be

processed at:

Name of Company (if different from SBTPA name):

Address:

City, State, Zip Code:

Telephone:

( )

E-mail address:

FAX:

( )

7. T

he SBTPA must offer workers' compensation insurance to its California domiciled employer

clients through an affiliated California domiciled insurance company.

Name of Company (if different from SBTPA name):

California Company ID # (issued by the

California Department of Insurance):

License/Certificate of Authority Status:

Date Authorized in California:

Address:

City, State, Zip Code:

Telephone:

( )

E-mail address:

FAX:

( )

; check(√), if none .

DE 2778 (3-11) (INTERNET) Page 2 of 4

SBTPA CONTACT INFORMATION

8. SB

TPA representative appointed to manage the administration of the voluntary plan:

Name:

Title:

Address:

City, State, Zip Code:

Telephone:

( )

E-mail address:

FAX:

( )

9. SB

TPA representative appointed to process disability claims:

Name:

Title:

Address:

City, State, Zip Code:

Telephone:

( )

E-mail address:

FAX:

( )

SECURITY DEPO SIT

10. Ty

pe of security that will be filed to secure the SBTPA voluntary plan:

Guarantee Bond, DE 2544V

Letter of Credit (based on the Model Letter of Credit provided by the EDD)

Cash

Bearer Bond(s)

NOTE: Do not send the security with this application. Instructions for sending the security will be

provided to the individual identified above in Question #8 upon approval of the plan. If cash is being

deposited, file the completed form, Agreement Regarding Deposit of Cash, DE 2545V, with this

application. If a bearer bond(s) is being deposited, file the form, Agreement Regarding Deposit of

Bearer Bond, DE 2545VB, with this app licat io n.

11. Estimated number of employers proj ected to participate in this SBTPA voluntary plan in the

first year of operation:

employers.

12. Estimated number of employees to be covered under this SBTPA voluntary plan in the first

year of operation:

employees; and their projected annual wages subject to the

SDI taxable wage ceiling: $ .

13. W i

thholding amount required of employees electing voluntary plan coverage:

. % of $

NOTE: Section 3254-1. (d), Title 22, California Code of Regulations provides that the employees’

contributions for disability benefits (including amounts designated as premiums)

will not exceed amounts greater than would be required if covered by the Disability Fund.

DE 2778 (3-11) (INTERNET) Page 3 of 4

MASTER TRUST ACCOUNT

14. T

he Master Trust Account (MTA) has been or will be established at the following Federal Deposit

Insurance Corporation (FDIC) Member Bank:

Subt

rust accounts will be created for each employer that becomes a client of the SBTPA.

15. T

he SBTPA will secure additional funding in the event that an employer’s trust monies are

inadequate to meet the employer’s voluntary plan obligations as follows:

NOTE: Section 3254,1.(c)(2), California Unemployment Insurance Code (CUIC) requires the establishment

of a master trust account that is administered by the SBTPA, but requires each individual employer that is a

client of the SBTPA to have subtrust accounts that reflect each client’s employees’ specific plan

contributions that are not commingled with any other client.

REQUIRED DOCUMENTS

Items 16 through 20 must be filed with this application:

16. C

opies of all informational documents which will be distributed to your client employers and their

employees to secure their consent for the voluntary plan.

17. C

opy of the SBTPA SIVP document/text previously approved by the Director of the EDD.

18. C

opy of the statement of coverage that will be given to all covered employees, if a statement of

coverage has been developed and will be distributed in place of the SBTPA SIVP document/text.

19 Copy of enrollment form(s) used to secure the employees’ consent to the plan; containing the

signature, date of consent, printed or typed name, and the Social Security Number.

20. Copies of all service agreements/contracts and related fee schedules that your client employers

will become subject to upon enlistment of your SBTPA services.

Bank Name:

Address:

City, State, Zip Code:

DE 2778 (3-11) (INTERNET) Page 4 of 4

CERTIFICATION

By signing below:

A. I am submitting an application for approval of a voluntary plan under the California

Unemployment Insurance Code (hereinafter identified as “Code”) and Title 22, California Code

of Regulations (hereinafter identified as “Regulations”).

B. I agree to operate the voluntary plan in conformity with the written terms and provisions of the

SBTPA SIVP document that was approved by the Director of the EDD and provided to the

EDD Voluntary Plan Administration Unit.

C. I agree to maintain the voluntary plan in effect for a period of not less than one year and,

thereafter, continuously, unless the Director of the EDD finds that the SBTPA has given notice

of withdrawal of the plan.

D. I agree that all disability and family leave insurance claims and benefits arising out of this

voluntary plan will be handled in accordance with the Code and Regulations.

E. I agree to pay any assessments which are levied in conformity with the Code and Regulations.

F. I agree to offer the plan to all eligible new employees, and will maintain available for inspection

by EDD representatives the signed consents of all employees for a period of not less than five

years.

G. I agree to post, upon request of the Director of the EDD, security in an amount determined by

the Director to be adequate to pay disability claims of my clients’ employees should the client’s

subaccount or the financial security provided by my clients be inadequate to meet the

obligations of this voluntary plan.

H. I certify that the foregoing statements, including any accompanying statements, are to the best

of my knowledge and belief true and correct.

By ___________________________________________________

(Must be signed by Owner, Partner, or Office r of th e Corporation)

__________________________________________ _

Print Name and Title

__________________________________________ _

Date

Mail completed application to: EDD, Disability Insurance Branch

Voluntary Plan Administration Unit, MIC 29 VP

PO Box 826880

Sacramento CA 94280-0001

If you have questions or need assistance completing this form, please call (916) 653-6839.