California Regulations 10202.1

• Final regulation section adopted, effective 10/01/04

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)

1. Union Information

Name of Union: Contact Person and Title:

Principal Address:

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. 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. Please attach proof of the union�s status as the exclusive bargaining representative of the employees in the above-described bargaining unit(s).

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 _____________________, CALIFORNIA ON __________________ (City) (Date)

BY:________________________________, TITLE:___________________________ (Original Signature of Union Representative)

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)

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