Cal. Code Regs. tit. 10 § 2592.12
EXPERIENCED CLAIMS ADJUSTER OR EXPERIENCED MEDICAL-ONLY CLAIMS ADJUSTER DESIGNATION
This Designation is awarded to
______________________________
(Adjuster's Name)
for: [] Experienced Claims Adjuster
[] Experienced Medical-Only Claims Adjuster
(Check Only One)
as a result of meeting the experience requirements for workers' compensation claims experience pursuant to California Insurance Code Section 11761 and California Code of Regulations, Title 10, Sections 2592.01 and 2592.05
Total Years of California Experience At Time of Designation: ____________ and/or Date Completed Examination Pursuant to Title 8, CCR Section 15452: ____________
Designation Given By:
______________________________
(Name of Insurance Company, Self-Insured Employer, or Third-Party Administrator)
| ___________________________ | ___________________________ | |
| (Date) | (Signature) |
Name of person awarding designation (print or type):
Title of person awarding designation:
Business address:
Cal. Code Regs. Tit. 10, § 2592.12
Note: Authority cited: Section 11761, Insurance Code. Reference: Section 11761, Insurance Code.