2021/04/27 City Council Resolution 2021-039 RESOLUTION NO. 2021-039
A RESOLUTION OF THE CITY COUNCIL OF THE CITY OF ROHNERT
PARK AUTHORIZING PARTICIPATION IN CALIFORNIA
INTERGOVERNMENTAL RISK AUTHORITY (LIRA)
EFFECTIVE JULY 19 2021 AND AUTHORIZING APPLICATION
TO THE DIRECTOR OF INDUSTRIAL RELATIONS, STATE OF
CALIFORNIA FOR A CERTIFICATE OF CONSENT TO SELF-INSURE
WORKERS' COMPENSATION LIABILITIES
WHEREAS, the CALIFORNIA INTERGOVERNMENTAL RISK AUTHORITY
(CIRA)provides risk-sharing, pooled workers' compensation coverage as a certificated self-
insured under the master certificate 5017 with the office of self-insured plans; and
WHEREAS,the CITY has been a member of the REDWOOD EMPIRE MUNICIPAL
INSURANCE FUND (REMIF) as a certificated self-insured under the master certificate 5013
with the office of self-insured plans;
WHEREAS,the BOARD of REMIF has taken action to join CIRA effective 7/l/2021
for all workers' compensation obligations that occur and/or are determined with a date of injury
7/l/2021 or after;
WHEREAS,the CITY of Rohnert Park has decided to approve the action of the BOARD
of REMIF and join CIRA as a member under master certificate 5017 effective July 1, 2021 for
all workers' compensation obligations that occur and/or are determined with a date of injury
7/1/2021 or after;
NOW, THEREFORE, BE IT RESOLVED by the City Council of the City of Rohnert
Park as follows:
1. The CITY hereby approves and authorizes participation in the CIRA workers'
compensation program
2. effective 7/l/2021 for all workers' compensation obligations that occur and/or are
determined with a date of injury of July 1, 2021 or after.
3. The City Manager is also authorized to execute any other document(s)that may be
necessary or appropriate to enter into and implement the agreement on behalf of the
CITY.
4. The CITY consents to be governed and abide by the master program documents, the
memoranda of coverage, and other documents and policies as adopted by the
CALIFORNIA INTERGOVERNMENTAL RISK AUTHORITY (CIRA) under master
certificate 5017.
BE IT FURTHER RESOLVED THAT City of Rohnert Park is authorized and
empowered to make application to the Director of Industrial Relations, State of California, for a
Certificate of Consent to Self-Insure workers' compensation liabilities and representatives of
Agency are authorized to execute any and all documents required for such application.
DULY AND REGULARLY ADOPTED this 27" day of April, 2021.
CITY O NERT PARK
G&Ajg_giu Mayor
ATTEST:
Sylvia Lopez C as, City Clerk
Attachments: Exhibit A
ADAMSLINARES:�STAFFORD EL5) AB �GIUDICE:
�&-AAYES: (C) OES: (�) ABSF, ( �) ABSTAIN: (�)
Resolution 2021-039
2
Form:A-2(1-2016) 1 Page 1
State of California
Department of Industrial Relations
Office of Self-Insurance Plans
11050 Olson Drive,Suite 230
Rancho Cordova,Ca.95670
Phone(916)464-7000
Fax(916)464-7007
State of California
Department of Industrial Relations
OFFICE OF SELF-INSURANCE PLANS
APPLICATION FOR CERTIFICATE OF CONSENT
TO SELF-INSURE AS A PUBLIC AGENCY EMPLOYER SELF-INSURER
All questions must be answered. If not applicable, enter"N/A".
To the Director of the Department of Industrial Relations: The public agency employer identified
below submits the following information to obtain a Certificate of Consent to Self-Insure the payment of
workers' compensation under California Labor Code Section 3700.
LEGAL NAME OF APPLICANT(Show exactly as on Charter or other official documents):
CITY OF ROHNERT PARK
Address: 130 AVRAM AVENUE
City: ROHNERT PARK State: CA Zip +4: 94928 1180
Federal Tax ID#of Group: 94-1538585
CONTACT-Who Should Correspondence Regarding This Applicant Be Addressed To:
Name: AMY NORTHAM Title: GENERAL MANAGER
Company Name: REDWOOD EMPIRE MUNICIPAL INSURANCE FUND (REMIF)
Address: 414 W. NAPA STREET 2ND FLOOR SUITE C
City: SONOMA State: CA Zip +4: 95476 1180
Phone: (707) 938-2388 E-Mail: anortham@remif.com
TYPE OF PUBLIC ENTITY(Check one):
F City and/or County ❑School District ❑Police and/or Fire District ❑Hospital District
❑Joint Powers Authority ❑Other (describe):
TYPE OF APPLICATION (Check one):
FNew Application ❑Reapplication (Merger/Unification) ®Reapplication (Name Change)
THE CITY HAS RESOLVED TO MOVE FROM ITS CURRENT JPA REDWOOD EMPIRE MUNICIPAL INSURANCE FUND,(REMIF MASTER
® Other(describe): CERTIFICATE 5013)TO CALIFORNIA INTERGOVERNMENTAL RISK AUTHORITY)CIRA-MASTER CERTIFICATE 5017)EFFECTIVE 711/2021.
NOTE:ONLY CLAIMS WITH DATES OF INJURY AFTER 7/1/2021 WILL BE INCLUDED IN THIS MOVE. REMIF WILL MAINTAIN RESPONSIBILITY
FOR ALL CLAIMS WITH DATES OF INJURY PRIOR TO 7/112021,
Date Self-Insurance Program will begin: 07/01/2021
Form:A-2(1-2016) 1 Page 2
CURRENT WORKERS'COMPENSATION PROGRAM
Currently Insured with State Fund Policy# Expiration Date:
Currently Self Insured, Certificate# 5013-007
Other (describe):
CLAIMS ADMINISTRATION
Who will be administering your agency's workers' compensation claims? (Check one)
®JPA will administer
FThird Party Administrator, TPA Certificate# 048-01
® Public entity will self-administer Insurance Carrier will administer
Name of Third Party Administrator:
Name: DOUGLASS GIBB Title: CLAIMS MANAGER
Company Name: ATHENS ADMINISTRATOR
Address: P.O. BOX 696
City: CONCORD State: CA Zip +4: 94522
Phone: (925) 826-1283 E-Mail: dgibb@athensadmin.com
#of claims reporting locations to be used to handle Agency's claims: 1
Does applicant currently have a California Certificate of Consent to Self-Insure?FYes®No
If yes, what is the current Certificate Number: 5013-007
Total Number of Affiliate's California employees to be covered by Group: N/A
AGENCY EMPLOYER
Current#of Agency Employees: 247 #of Public Safety Employees (police//fire): 74
If school District, #of certificated employees: N/A
Will all Agency employees be covered by this self-insurance plan? FYes ®No
If'No', explain who is not covered and how workers' compensation coverage will be provided to the
excluded employees:
Form:A-2(1-2016) l Page 3
JOINT POWERS AUTHORITY
Will applicant be a member of a JPA for workers' compensation ?
FYes F No (If'yes', complete the following)
Effective date of JPA Membership: 07/01/2021 JPA Certificate# 5017
Name of JPA: CALIFORNIA INTERGOVERNMENTAL RISK AUTHORITY (CIRA)
NOTE:CIRA FORMERLY KNOWN AS PUBLIC AGENCY RISK SHARING AUTHORITY OF CALIFORNIA(PARSAC). NAME CHANGE EFFECTIVE 7/1/2021.
REMIF WILL MAINTAIN RESPONSIBILITY FOR ALL CLAIMS WITH DATES OF INJURY PRIOR TO 7/1/2021. ONLY CLAIMS WITH DATES OF INJURY ON OR
AFTER 7/1/2021 WILL BE INCLUDED IN THIS MOVE.
AGENCY SAFETY PROGRAM
Does the Agency have a written Injury and Illness Prevention Program (IIPP)? F Yes ®No
Individual responsible for Agency workplace safety and IIPP program:
Name: VICTORIA PERRAULT Title: HUMAN RESOURCES DIRECTOR
Company Name: CITY OF ROHNERT PARK
Address: 130 AVRAM AVENUE
City: ROHNERT PARK State: CA Zip +4: 94928
Phone: (707) 558-2221 E-Mail: vperrault@rpcity.org
SUPPLEMENTAL COVERAGE
1.)Will your program be supplemented by gnv nsurclnrg or pooled coverage under a STANDARD
workers' compensation insurance policy? Yes E No (if'Yes', complete the following):
Name of Excess Pool/Carrier: N/A
Policy#: N/A Effective Date of Coverage:
2.)Will your program be supplemented by any insurance or po coverage under a SPECIFIC
EXCESS workers' compensation insurance policy? O Yes �No (If'Yes', complete the following):
Name of Excess Pool/Carrier: PENDING (CURRENTLY INSURED WITH SAFETY NATIONAL)
Policy#: PENDING Effective Date of Coverage: 07/01/2021
Retention Limits: PENDING (CURRENTLY $1 M FOR PEACE AND FIRE AND$750K FOR ALL OTHER)
3.)Will your program be supplemented by any insurance or pooled coverage under an AGGREGATE
EXCESS (stop loss) specific excess workers' compensation insurance policy? Yes No
(If'Yes', complete the following):
Name of Excess Pool/Carrier:
Policy#: Effective Date of Coverage:
Retention Limits:
Form: A-2 (1-2015) | Page 4
RESOLUTION GOVERNING BOARD
Attach a properly executed Governing Board Resolution. See attached sample resolutlon on page 5.
The undersigned on behalf of the applicant hereby applies for a Certificate of
Consent to Selflnsure the payment of workers' compensation liabilities pursuant
to Labor Code Section 3700. The above information is submitted for the purpose
of procuring said Certificate from the Director of lndustrial Relations, State of
California. lf the Certificate is issued, the applicant agrees to comply with
applicable California statutes and regulations pertaining to the payment of
compensation that may become due to the applicant's employees covered by the
Certificate.
DATE UZI
SIGNED Offi cial / Representative
Darrin Jenkins
Printed Name
City Manager
Title
CITY OF ROHNERT PARK
Agency Name
CERTIFICATION
Form:A-2(1-2016) 1 Page 5
RESOLUTION NO.: 2021-039 DATED: 04/27/2021
A RESOLUTION AUTHORIZING APPLICATION
TO THE DIRECTOR OF INDUSTRIAL RELATIONS, STATE OF CALIFORNIA
FOR A CERTIFICATE OF CONSENT TO SELF-INSURE
WORKERS' COMPENSATION LIABILITIES
At a meeting of the City Council
(Enter Name of the Board)
of the CITY OF ROHNERT PARK
(Enter Name of Public Agency,District.Etc.)
a CITY ter Type organized and existing under the
(En of Agency.i.e..County,City,School Distract,etc.)
laws of the State of California, held on the 27th day of April 2021
the following resolution was adopted:
RESOLVED, that the above named public agency is authorized and empowered to
make application to the Director of Industrial Relations, State of California, for a
Certificate of Consent to Self-Insure workers' compensation liabilities and
representatives of Agency are authorized to execute any and all documents
required for such application.
IN WITNE S EREOF: I HAVE SIGNED AND AFFIXED THE AGENCY SEAL.
p
X DATE: l2-1
SIGNED: Boar ecretary or Chair
Gerard Giudice
Printed Name
Mayor
Title
City of Rohnert Park Affix Seal Here
Agency Name