All forms and waivers require Adobe Acrobat. If you do not have Adobe Acrobat, please click here.
Complete and fax Requests for Certificates of Insurance, Hold Harmless Agreements, and Facility Use Agreements to the Risk Services Office in Oakland at (510) 987-0965. For questions regarding the processing and/or submittal of a form or waiver, contact Linda Harris at (510) 987-0085 Linda.Harris@ucop.edu
Attachment A: Preferred Hold Harmless and Indemnification Clause
If a facility use agreement contains a clause that compromises The Regents' assets by leaving open the potential for lawsuits from any and all parties, the County Director or Regional Director need to review the language and negotiate changes to the contract language (helpful hints for Attachment A).
Attachment B: Alternate Hold Harmless and Indemnification Clause
If a facility use agreement contains a clause that compromises The Regents' assets by leaving open the potential for lawsuits from any and all parties, the County Director or Regional Director need to review the language and negotiate changes to the contract language (helpful hints for Attachment B).
Attachment C: Request for Certificate of Insurance (.pdf)
Attachment C: Request for Certificate of Insurance (.doc)
To submit the Request via email (requires MS Word): Download the MS Word Document (.doc). Enter the necessary information directly into the document. Save the file to your computer. Create an email addressed to Linda.Harris@ucop.edu and attach the file to the email. All additional documentation must be FAXED to the Risk Services Office at (510) 987-0965.
If you do not have MS Word: Download the Adobe Acrobat file (.pdf) and print the Request. Complete the required information and submit the Request via fax to (510) 987-0965.
Attachment D Preferred ANR Use Agreement (pdf)
Attachment E Alternate ANR Use Agreement (pdf)
Incident Report 2008
Any incident resulting in property loss/damage and/or causalities must be reported using this form.
Subsequent Arrest Notification/No Longer Inerested Form (blank)
Subsequent Arrest Notifcation/No Longer Interested Form (semi-filled)
Business Travel Accident Insurance
Student off Campus Travel Accident Insurance
Elective/Voluntary Activity Waivers
English and in Spanish covering liability issues for elective/voluntary events, including 4-H programs.
Facilities Use Indemnification Agreement with the Division of Fairs and Expositions
Mutually agreed upon Hold Harmless and Indemnification language to be used in agreements at County and State Fair facilities.
Facilities Use Indemnification Agreement with the CSU
Mutually agreed upon Hold Harmless and Indemnification language to be used in agreements at CSU facilities.