Insurance - Orange County Department of Education - 2015-07-01 (2) EVIDENCE OF COVERAGE DARBMDOPI '''
1027/2015
This Evidence of Coverage is used as a matter of Information only and confers no rights upon the Certificate Holder. This Evidence of Coverage does not
amend,extend,or alter the coverage afforded by the memoranda listed below.
MEMORANDUM NUMBER: 74
JOINT POWERS AUTHORITY Ifl JM MEMBER
Alliance of Schools for Cooperative Insurance Programs Orange County Department of Education
16550 Bloomfield Avenue 200 Kalmus Drive
Cerritos, CA 90703 Costa Mesa CA 92626
wwwASCIP.org
CONTACTRAMe Mr.Fre Heldch,Chief Executive Officer
PHONE:(562)404-8029
This Is to certify that the Alliance of Schools for Cooperative Insurance Programs(ASCIP) Memorandum of Coverages on insurance listed below have
been issued to the Covered Party named above for the period indicated. Notwithstanding any requirement,term,or condition of any contract or other
document with respect to which this Evidence of Coverage may be used or may pertain,the coverages afforded by the Memorandum of Coverage
described herein are subject to all the terms,exclusions,and conditions of such Memorandum of Coverages.
EPPTYPE OF COVERAGE ri: O MEMORANDUM NUMBERIMOC) #AL POLICPPO�� UNIFY OF WBUTYI COVERAGE
GENERAL LMBERY COMBINED SINGLEUM,PER IXg1RRENCE $ 15,000,000
,7 OCCURRENCE / MOC #74 7/1/2015 7/1/2016 AGGREGATE 1 NIA
▪ Personal injury g
L Errors&Omission
Empbyment Practices
5
AUTOMOBILE LIABILITY CTMBNED SEIGLE LIMIT PER OCCURRENCE E $5,000,000
_L AUTOMOTIVE PHYSICAL DAMAGE MOC #74 7/1/2015 7/12016 ACTUAL CARR VALUE 1
L COMPREHENSIVE/COLLISION 1
SHY AUTO
s
�. Ovmed Auto 1
Hired Auto
S
PRCPERT• REPLACEMENT COST 9lI81ECTTO PFLCYLRAM.TERMS.
AND CCHDRIRY9
BUILDING/CONTENTS
S
FIRE THEFT RENTAL INTERRLP1ICN
E
S
S
WORICERSCppENMTNN NIA EACHA0.^YENT a
AND EMPLOYERS'LIABILITY
DAC STATUTORY LOAM PER EMPLOYEE E
POLCY LIMIT a
OTHER SUBJECTED POLICY LRAM TERMS AND WipnKNS
EMPLOYEE MSHONESTY CRIMEI
— 9
$
— S
— 1
ADDITIONAL REMARKS:
As respects to OCDEs Inside the Outdoors Program will provide"Project Zero Waste"waste reduction education for Costa mesa students Agreement*42192
CERTIFICATE HOLDER CANCELLATION
Should any of the above coverages for the Covered Party be changed or withdrawn prior
to the expiration date issued above, ASCIP will mail 30 days written notice to the
Certificate Holder,but failure to mail such notice shall impose no obligation or Ilablltty of
Costa Mesa Sanitation District any kind upon ASCIP,its agents,or representatives.
Mn: District Clerk
628 West 19th Street
Costa Mesa CA 92627 / " //�"
/ .
ImRIR
AMO REPREESESENT`A_TNE: Fritz Heirich
'MOAN a Mirk posers MdurMWrsuan oANYel(comma-Amy me DADA 650)lCNper 5 N MIME 7 of Me Id the GovernmentCodeandSal'grs39563aNMoRoMmEdI[Mbn Code. by NV
21065292 : 74 15.16 all Types Emmy ayes /o,e7/2o15 12211./2 LI lPUT) I pave 1 of 2
Additional Covered Party Endorsement
Oran aEndorsement No.
District: County e Department of Education
27066202
Additional Covered Party: - Description of Operations,Vehicle, or Property:
Costa Mesa Sanitation District As respects to OCDEs Inside the Outdoors Program will provide
"Pro ed Zero Waste"waste education reduction or Costa mesa
is e directors,officials,omras,emla eesoea ante and volluunteers ahaestudlenls Agreement#42192 -
ani or equipmen srOhed con�nTA11Nh sludiiuwoirt( Mee'
nsurance coverage shall be primary Insurance as respects the
/)aautrnd,tas dnadorse.omdals tohecCONm TANTs amesnacend a
nd shat
e called
upon to conbtbule with It In anyway
Coverage Period: Effective:7nrz01s Expires 12:01 a.m.wi/2016
The coverage provided to the Covered Party is hereby extended by this endorsement to the Additional Covered Party named above
in accordance with the provisions contained in the Memorandum of Coverage(MOC). The coverage extended hereby applies only
with respect to liability arising out of activities in the Description of Operations,Vehicle,or Property noted above.It is intended by
ASCIP in issuing this endorsement to defend and/or indemnify the Additional Covered Party only if the District is solely negligent.
In issuing this endorsement, ASCIP intends and agrees to extend coverage pursuant to the terms and conditions of the MOC to the
Additional Covered Party named above only to the extent that the Additional Covered Party faces liability arising out of claims,
demands,or lawsuits claiming money damages on account of bodily injury or property damage as defined and limited in the ASCIP
blOC. The limits of liability extended to the Additional Covered Party listed above is$1,000,000 per occurrence for liability. Such
insurance as afforded by this policy shall be primary,and any insurance carried by the Additional Covered Party named above shall
be in excess and non-contributory.
Authorized Representative: _ _-
Date Issued:10/27/2015
ASCIP is a,joint powers authority pursuant to Article I (commencing wilt Section 6500)of Chapter 5 of Division 7 of Title I of the Gm emment
Code and Sections 39603 and M603 of the Education Code.
Rev 5.97
270(6292 74 1E16 :-.11 'types aency:ogee 12/27p012 10.11.17 221 Wool 2a9e 2 of 2
4N9E COUP),.
fl
ORANGE COUNTY July 1, 2015
DEPARTMENT
OF EDUCATION
:N.0 K6'J, 11S DRIVE
EC E.CX Ea'...'.
.,:)SLL.. +.1U .'
.x(1'4)432-'s a Re: Verification of Workers' Compensation Coverage
CPB S
To Whom It May Concern:
The Orange County Superintendent of Schools is self-insured for it Workers'
Compensation coverage through the Western Orange County Self-Funded
Workers' Compensation Agency, a Joint Powers Authority(WA). Our self-
insured certificate number is A-5532-10-132.
If you are in need of further details or have any questions,please feel free to
contact me at(714) 966-4059.
Sine ely,
Aim Kantor, Coordinator
Risk Management
ditAri;i;i C i ,.`.:
3UAFII 11 (i?CU!'.i:,
.OHN' W U DELL, 'H1
DAVIT)L BIND
FOBLR`N HAMIKONE
LINEA t INDHOIV
KEN L W I I IAM i,It(,
Maggie Solorzano
From: Parvin Dashtaki
Sent: Wednesday,October 28,2015 9:10 AM
To: Maggie Solorzano
Subject: Costa Mesa Sanitation District COI
Attachments: Costa Mesa Sanitation District #42192.pdf
Hi
Maggie;
The following is the response from ASCIP on additional covered party:
"Our certificate templates are standard and we can't make any changes to it.So to the missing#3 clause we can't
add or revise our template."
Also,bringing you the W/C Verification coverage separately.
Thanks.
Yawl's Dasata4i
Administrative Assistant III
Risk Management
Tel:714-966-4033
Fax:714-549-4812
pdashtaki@ocde.us
LAW OFFICES OF
HARPER& BURNS LLP
A u W1ED UAYIIR FARRRR9RP INCLUDING A PROVesSiliet3.3t 101300.110N
JOHN R.HARPER. 453 SOUTH GLASSELL SrRFFT
ALAN R.BURNS ORANGE,GVJ FORNIA 8846
COLIN R.BURNS
ALEX M BALFMAN TELEPHONE(714)771-7778
FACSIMILE(114)744-3350
A PRWE5510.3AL COUOFATIW Alen M NL(vun
anhal6maogilurpecturnsmm
Confidential Attorney-Client Privileged
To: Management Analyst
From: District Counsel
Date: November 9, 2015
Re: Review of Insurance for Orange County Department of Education
Typically, insurers use forms as evidence of insurance coverage. The Orange County Department
of Education is a part of a joint powers commission, which obtains insurance coverage through
contract. These types of contracts are typically reliable.
The Evidence of Coverage shows that there is a general liability and automobile liability policy
under the contract. However, without reviewing the actual contract, we cannot know exactly
what kind of insurance is provided. Because these types of contracts are generally reliable, we are
comfortable moving forward if you are. If you are not comfortable moving forward without us
reviewing the contract for insurance,please send us the insurance contract for our review.
HARPER
/&&BURNS LLP
•• r
Alex M. Halfman
Associate