SELF-INSURED GROUP ROSTER 03/04/2020

SELF-INSURED GROUP ROSTER Note: The first digit in the Certificate Box represents Administered or Self Administered

Self Administered and Administered is (1) Self Administered is (2) Administered is (3)

03/25/2021

3 4500

Cert Effective Date: 01/01/2002

Auto Dealers Compensation Of California, Inc.

Jeffrey J. Bogacki

5star Specialty 101 West Ave, Ste 150 Jenkintown, PA 19046 (267)289-1776 NAICS Code: 55

Revoked

Revoke Effective Date: 01/01/2013

TPA 316-02 316-03

Corvel Enterprise Comp, Inc. - Rancho Cucamonga Corvel Enterprise Comp, Inc. - San Diego

3 4501

Cert Effective Date: 02/27/2003

Guardiancomp, Inc.

Jackie Harris

Rps Monument 255 Great Valley Parkway, Ste 200 Malvern, PA 19355 (610)647-4466 NAICS Code: 62

Active

TPA 048-01

Athens Administrators - Concord

3 4502

Cert Effective Date: 05/01/2003

Active

California Truckers Safety Association Workers Compensation Program, Inc.

Greg S. Famous

Avi Risk Services 200 North Warner Rd, Ste 240 King of Prussia, PA 19406 (610)975-6053 NAICS Code: 48

TPA 152-10

Lwp Claims Solutions, Inc. - Sacramento

3 4503

Cert Effective Date: 06/16/2003

California Contractors Network, Inc.

Travis Harper

Self Insured Solutions 430 N. Vineyard Ave, #102 Ontario, CA 91764 (800)592-0047 NAICS Code: 23

Active

TPA 334-01

American Claims Management, Inc. - San Diego

3 4504

Cert Effective Date: 09/12/2003

Preferred Auto Dealers Self-Insurance Program, Inc.

Gene Axtell

Affinity Group Administrators 8863 Greenback Lane #211 Orangevale, CA 95662 (916)550-9489 NAICS Code: 44

Revoked

Revoke Effective Date: 03/01/2009

TPA

3 4506

Cert Effective Date: 01/01/2004

Active

Members Members Members Members Members

Elite Golf Club Program, Inc.

Su Adams Avi Risk Services 200 North Warner Rd, Ste 240 King of Prussia, PA 19406 (610)975-8252 NAICS Code: 71

TPA 048-01

Athens Administrators - Concord

3 4507

Cert Effective Date: 01/01/2004

Plastic Manufacturers Self Insurance Program, Inc.

Gene Axtell

Affinity Group Administrators 8863 Greenback Lane, Ste 211 Orangevale, CA 95662-4059 (916)983-3387 NAICS Code: 32

Revoked

Revoke Effective Date: 01/01/2007

TPA

3 4508

Cert Effective Date: 02/01/2004

Active

Credit Union Self Insured Group Of California, Incorporated

Gene Axtell

Affinity Group Administrators 8863 Greenback Lane #211 Orangevale, CA 95662 (916)550-9489 NAICS Code: 52

TPA 146-05

Acclamation Insurance Management Services - Sacramento

3 4509

Cert Effective Date: 03/01/2004

Revoked

Auxiliary Organizations Workers' Compensation Plan, Inc.

Rob Leong

Auxiliary Organizations Workers' Compensation Plan, Inc. c/o Alliant Insurance Services 600 Montgomery St Ste 900 San Francisco, CA 94111-2711 NAICS Code: 81

Revoke Effective Date: 01/01/2005

TPA 011-23

Sedgwick Claims Management Services, Inc. - Rancho Cordova

3 4510

Cert Effective Date: 04/15/2004

Revoked

Beverage Distributors Of California Self-Insured Group, Inc.

Gene Axtell

Beverage Distributors Of California Self-Insured Group, Inc. c/o Affinity Group Administrators P.O. Box 7138 Folsom, CA 95763-7138 (916)983-3387 NAICS Code: 42

Revoke Effective Date: 01/01/2011

TPA

3 4511

Cert Effective Date: 07/01/2004

Cornerstone Comp, Inc.

Active

Members Members Members Members Members Members

Jerry Laval

The Path Alliance, Inc. 7060 N. Marks Ave, Ste 118 Fresno, CA 93711 (559)558-4800 NAICS Code: 62

TPA 152-10

Lwp Claims Solutions, Inc. - Sacramento

3 4513

Cert Effective Date: 10/01/2004

Nonprofits' United Workers' Compensation Group, Inc.

Irene McMillan

Nonprofits' United 610 Fulton Ave, Ste 200 SACRAMENTO, CA 95825 (916)868-6228 NAICS Code: 62

Active

TPA 132-10 132-01

York Risk Services Group, Inc. - Rancho Cucamonga York Risk Services Group, Inc. - Roseville

3 4514

Cert Effective Date: 12/01/2004

Active

California Private Schools Workers' Compensation Self-Insurance Group, Inc.

Jackie Harris

Rps Monument 255 Great Valley Parkway, Ste 200 Malvern, PA 19355 (610)647-4466 NAICS Code: 61

TPA 048-01

Athens Administrators - Concord

3 4515

Cert Effective Date: 12/01/2004

Quality Comp, Inc.

Jackie Harris

Rps Monument 255 Great Valley Parkway, Ste 200 Malvern, PA 19355 (610)647-4466 NAICS Code: 62

Active

TPA 048-01

Athens Administrators - Concord

3 4516

Cert Effective Date: 01/01/2005

California Agricultural Network, Inc.

Travis Harper

Self Insured Solutions 430 N Vineyard Ave #102 Ontario, CA 91764 (800)592-0047 NAICS Code: 11

Active

TPA 239-07

Intercare Holdings Insurance Services, Inc. - Fresno

Members Members Members Members

3 4517

Cert Effective Date: 12/01/2004

California Restaurant Mutual Benefit Corporation

Travis Harper

Self Insured Solutions 430 N. Vineyard Ave, #102 Ontario, CA 91764 (800)592-0047 NAICS Code: 44

Active

TPA 152-10

Lwp Claims Solutions, Inc. - Sacramento

3 4518

Cert Effective Date: 03/01/2005

Revoked

Western Independent Bankers Self Insurance Program Of California

Gene Axtell

Affinity Group Administrators P.O. Box 7138 Folsom, CA 95763-7138 (916)550-9489 NAICS Code: 52

Revoke Effective Date: 07/22/2010

TPA

3 4519

Cert Effective Date: 03/16/2005

Auto Dealer Access, Inc.

Michael W. Kiger

Auto Dealer Access, Inc. 2500 Via Cabrillo Marina San Pedro, CA 90731-7224 (310)832-8900 NAICS Code:

Revoked

Revoke Effective Date: 03/13/2005

TPA

3 4520

Cert Effective Date: 07/01/2005

Victory Comp, Inc.

Jackie Harris

Rps Monument 255 Great Valley Parkway, Ste 200 Malvern, PA 19355 (610)647-4466 NAICS Code: 62

Active

TPA 048-01

Athens Administrators - Concord

3 4521

Cert Effective Date: 08/01/2005

California Farm Management, Inc.

Travis Harper

Self Insured Solutions 430 N. Vineyard Ave, #102 Ontario, CA 91764 (800)592-0047 NAICS Code: 11

Active

TPA 239-07

Intercare Holdings Insurance Services, Inc. - Fresno

3 4522

Cert Effective Date: 08/01/2005

Revoked

Revoke Effective Date: 12/01/2008

Vintners And Independent Producers Self Insurance Program Of California

Members Members Members Members Members Members

Stephen Ungar

Amtrust North America, Inc. 101 California Street, 22nd Floor San Francisco, CA 94111 NAICS Code: 31

TPA

3 4523

Cert Effective Date: 09/13/2005

Revoked

Revoke Effective Date: 04/01/2009

Fabricated Metal Products Of California Workers' Compensation Group, Inc.

Greg Famous

Avi Risk Services, Llc 985 Old Eagle School Rd, Ste 504 Wayne, PA 19087 (610)975-6053 NAICS Code: 33

TPA

3 4524

Cert Effective Date: 07/01/2005

Finish Line Self Insurance Group, Inc.

G. Michael Lyon

Finish Line Self Insurance Group, Inc. 4961 Katella Ave Los Alamitos, CA 90720 (714)820-2743 NAICS Code: 71

Active

TPA 358-01

Finish Line Self Insurance Group, Inc - Los Alamitos

3 4525

Cert Effective Date: 12/01/2005

California Agricultural Products, Inc.

Travis Harper

Self Insured Solutions 430 N. Vineyard Ave, #102 Ontario, CA 91764 (800)592-0047 NAICS Code: 11

Active

TPA 152-10

Lwp Claims Solutions, Inc. - Sacramento

3 4526

Cert Effective Date: 12/01/2005

Household Industries Self-Insured Group

Travis Harper

Self Insured Solutions 430 N. Vineyard Ave, #102 Ontario, CA 91764 (800)592-0047 NAICS Code: 44

Active

TPA 048-01

Athens Administrators - Concord

3 4527

Cert Effective Date: 01/01/2006

Active

Food Products Of California Workers Compensation Program, Inc.

Greg S. Famous

Members Members Members Members Members

Avi Risk Services 200 Warner Rd, Ste 240 King of Prussia, PA 19406 (610)975-6053 NAICS Code: 31

TPA 011-05

Sedgwick Claims Management Services, Inc. - Orange

3 4528

Cert Effective Date: 01/01/2006

California Livestock Producers, Inc.

Active

Travis Harper

Self Insured Solutions 430 N. Vineyard Ave, #102 Ontario, CA 91764 (800)592-0047 NAICS Code: 11

TPA 239-07

Intercare Holdings Insurance Services, Inc. - Fresno

3 4529

Cert Effective Date: 07/01/2007

Active

Northern California Auto Dealers Self-Insurance Group, Inc.

Greg S. Famous

Avi Risk Services 200 Warner Rd, Ste 240 King of Prussia, PA 19406 (610)975-6053 NAICS Code: 44

TPA 152-10

Lwp Claims Solutions, Inc. - Sacramento

3 4530

Cert Effective Date: 01/01/2008

Medical Affiliated Groups Insurance Of California

Active

Lisa A. Overholt

Keenan & Associates 2355 Crenshaw Blvd., #200 Torrance, CA 90501 (310)212-0363 NAICS Code: 62

TPA 195-05

Tristar Risk Management - Rancho Cordova

3 4531

Cert Effective Date: 02/01/2008

Active

Entertainment Employees Workers Comp Program, Inc.

Greg S. Famous

Avi Risk Services 240 North Warner Rd, Ste 240 King of Prussia, PA 19406 (610)975-6053 NAICS Code: 72

TPA 011-05

Sedgwick Claims Management Services, Inc. - Orange

3 4532

Cert Effective Date: 04/05/2013

Active

Members Members Members Members

California Healthcare Industry Program

Travis Harper

Self Insured Solutions 430 N. Vineyard Ave, #102 Ontario, CA 91764 (800)592-0047 NAICS Code: 62

TPA 239-06

Intercare Holdings Insurance Services, Inc. - Glendale

3 4533

Cert Effective Date: 07/01/2017

Post Time Self Insurance Group

Active

Michael Lyon

Sig Solutions 4961 Katella Ave Los Alamitos, CA 90720 (714)820-2786 NAICS Code:

TPA 358-01

Finish Line Self Insurance Group, Inc - Los Alamitos

3 4534 Ag Select, Inc.

Cert Effective Date: 04/01/2021

Active

Jerry Laval

The Path Alliance 7060 N. Marks Ave #118 Fresno, CA 93711-9016 (559)558-4800 NAICS Code: 115

TPA 152-10

Lwp Claims Solutions, Inc. - Sacramento

3 4535

Cert Effective Date: 04/01/2021

Better Living Comp, Inc.

Active

Jerry Laval

The Path Alliance 7060 N. Marks Ave, #118 Fresno, CA 93711 (559)558-4800 NAICS Code: 238

TPA 152-10

Lwp Claims Solutions, Inc. - Sacramento

Members Members Members Members

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