1. 1. Union Information

   Name of Union:

   Contact Person and Title:

   Principal Address:

2. 2. Employer Information (For group of employers, please use separate pages to list all individual employers.)

   Name of Employer:

   Contact Person and Title:

   Federal Employers Identification Number (FEIN):

   Principal Business of Employer:

   Principal Address:

3. 3. Please describe the bargaining unit or units to be covered by the Section 3201.7 labor-management agreement, and provide the approximate number of employees in the unit(s).
4. 4. Please attach proof of the union's status as the exclusive bargaining representative of the employees in the above-described bargaining unit(s).

5. 5. Please attach a copy of the current collective bargaining agreement or agreements in effect between the union and the employer.

   I declare under penalty of perjury under the laws of the State of California that the foregoing is true and correct.

   EXECUTED AT ______________________________(City), CALIFORNIA ON ____________________(Date)

   BY: ________________________________________(Original Signature of Union Representative), TITLE: ______________________________

   You must attach a proof of service by mail declaration indicating that the petition and all supporting evidence was mailed to the employer, or for a group of employers, all individual employers.

   DWC Form RGS-1 (012004)

STATE OF CALIFORNIA

Department of Industrial Relations

Division of Workers' Compensation

Administrative Director

Post Office Box 420603

San Francisco, CA 94142-0603

Telephone: (415) 703-4600

Petition for Permission to Negotiate a Section 3201.7 Labor-Management Agreement

Labor Code § 3201.7; Title 8, California Code of Regulations § 10202

Please submit the following information to the Administrative Director of the Division of Workers' Compensation to obtain a letter advising the below-named union and employer, or group of employers, of their eligibility to enter into negotiations for the purpose of reaching agreement on a labor-management agreement authorized by Section 3201.7 of the California Labor Code.

(Print or Type Name and Addresses)

Note: Authority cited: Sections 133 and 5307.3, Labor Code. Reference: Section 3201.7, Labor Code.

History

1. New section filed 4-22-2004 as an emergency; operative 4-22-2004 (Register 2004, No. 17). A Certificate of Compliance must be transmitted to OAL by 8-20-2004 or emergency language will be repealed by operation of law on the following day.

2. Certificate of Compliance as to 4-22-2004 order, including further amendment of section, transmitted to OAL 8-20-2004 and filed 10-4-2004 (Register 2004, No. 41).