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					                          LO S AN G EL E S CO M M UN IT Y CO LL EG E D I S T RICT
                              DEPARTMENT OF FACILITIES PLANNING AND DEVELOPMENT
                                         PROPOSITION A/AA BOND PROGRAM



            INSTRUCTIONS FOR COMPLETING, EXECUTING, AND SUBMITTING
                            EVIDENCE OF INSURANCE


INSURED:                                                              DATE:

AGREEMENT/REFERENCE NO.:

1.     INSURED

       a.      In order to reduce problems and time delays in providing evidence of insurance to the Los
               Angeles Community College District (LACCD), you are requested to give your insurance
               agent or broker a copy of the captioned agreement along with these instructions and
               endorsement forms for completing, executing, and submitting evidence of insurance.

       b.      All questions relating to insurance should be directed as indicated below.

2.     INSURANCE AGENT OR BROKER

       a.      The appropriate endorsement form shall be used where required. No changes in the terms
               or conditions of the endorsement forms will be permitted. Certificates of Insurance alone will
               not be accepted by LACCD.

       b.      The name of the insurance company underwriting coverage and its address shall be noted on
               the endorsement form.

       c.      The coverages and limits for each type of insurance are specified in the agreement.

       d.      You shall have an authorized representative of the underwriting insurance company sign the
               completed endorsement form and transmit the forms as indicated below. Signatures must be
               originals.  Facsimile (rubber stamp, photocopy, etc.) or initialed signatures are not
               acceptable.

       e.      The endorsement form shall include reference to the activity and/or to either the specific
               contract number.

       f.      Endorsements to excess policies will be required when primary insurance is insufficient in
               complying with the contract requirements.

       g.      Improperly completed endorsements will be returned to your insured for correction by an
               authorized representative of the insurance company.

       h.      Delay in submitting properly completed endorsement forms may delay your insured’s
               intended occupancy or operation under agreement with LACCD.

       i.      Completed endorsement(s) and questions relating to the required insurance are to be
               directed to:
                                           DMJM/JGM Program Management
                                           Los Angeles Community College District
                                             Proposition A & AA Bond Program
                                             Attention: Francine Gonzalez
                                          515 South Flower Street, Ninth Floor
                                             Los Angeles, CA 90071-2201



Form PA-0058                                           Page 1 of 12                              Rev.1-08.25.03
                        LO S AN G EL E S CO M M UN IT Y CO LL EG E D I S T RICT
                            DEPARTMENT OF FACILITIES PLANNING AND DEVELOPMENT
                                     PROPOSITION A/AA BOND PROGRAM



                              INSURANCE REQUIREMENT FORM

INSURED:                                DATE:

AGREEMENT/REFERENCE NO.:


The following coverages and limits noted below are required.

CERT./END./LOSS PAYEE

X/ /       Workers’ Compensation                                 Part One: Statutory



X/ /       Employer’s Liability                                  Part Two:
                                                                    Bodily Injury by Accident
                                                                    ($1,000,000 each accident)
                                                                    Bodily Injury by Disease
                                                                    ($1,000,000 per policy period)
                                                                    Bodily Injury be Disease
                                                                    ($1,000,000 each employee)

           ( ) Broad Form All States Endorsement
           ( ) Longshore and Harbor Workers’
               Compensation Act Endorsement

X/X/       ISO Commercial General Liability Coverage
           Form (“occurrence” form only)                         $1,000,000

                                                                 $2,000,000 General Aggregate
                                                                 $      _ Specific Aggregate

           (X)   Premises and Operations                         (X)   Explosion Hazard
           (X)   Contractual Liability                           ( )   Garagekeeper’s Legal Liability
           (X)   Independent Contractors                         ( )   Hangarkeeper’s Legal Liability
           (X)   Products/Completed Operations                   (X)   Collapse Hazard
           (X)   Broad Form Property Damage                      ( )   Watercraft Liability
           ( )   Personal Injury and Advertising Injury          (X)   Underground Hazard
           (X)   Broad Form Liability Endorsement                ( )   Sexual Molestation
           (X)   Fire Legal Liability                            ( )   Medical Payments
           ( )   Incidental Medical Expense




Form PA-0058                                      Page 2 of 12                              Rev.1-08.25.03
                          LO S AN G EL E S CO M M UN IT Y CO LL EG E D I S T RICT
                              DEPARTMENT OF FACILITIES PLANNING AND DEVELOPMENT
                                         PROPOSITION A/AA BOND PROGRAM




 CERT./END./LOSS PAYEE                                                       MINIMUM LIMITS


   X/X/         ISO Business Automobile Liability
                Coverage Form No. CA 00 01                          $1,000,000 CSL*

                (X) Any Automobiles                                 ( ) Owned Automobiles
                ( ) Non-owned Automobiles                           ( ) Hired Automobiles

    / /         Aviation/Airport Liability                          $

    / /         Professional Liability                              $

    / /         Directors and Officers                              $

   X/ /X        ISO Commercial Building and Personal
                Property Coverage Form (CP 00 10)                   $ Full Replacement Cost

                ( ) Extended Coverage                               ( ) Sprinkler Leakage
                ( ) Vandalism & Malicious Mischief                  ( ) Debris Removal
                ( ) All Risk (ISO Cause of Loss Form-               ( ) Flood
                    Special Form CP 10 30)
                (X) Builder’s Risk Coverage Form (CP 00 02)
                ( ) Earthquake $
                ( ) Other

    / /         Ocean Marine                                        $

                ( ) Protection & Indemnity                          ( ) Cargo
                ( ) Charter’s Legal Liability                       ( ) Jones Act

    / /         Crime Coverage                                      $

                ( ) Blanket Employee Dishonesty                     ( ) Forgery or Alteration
                ( ) Theft, Disappearance, and Destruction           ( ) Computer Fraud

    / /         Student Accident                                    $

                ( ) Accidental Death, Dismemberment, and
                    Loss of Sight
                ( ) Hospital and Professional Medical
                    Services




*CSL = Combined Single Limits



 Form PA-0058                                        Page 3 of 12                           Rev.1-08.25.03
                      LO S AN G EL E S CO M M UN IT Y CO LL EG E D I S T RICT
                          DEPARTMENT OF FACILITIES PLANNING AND DEVELOPMENT
                                    PROPOSITION A/AA BOND PROGRAM




       COMMERCIAL GENERAL LIABILITY AND BUSINESS AUTOMOBILE LIABILITY
                     ADDITIONAL INSURED ENDORSEMENT


In consideration of the premium charged and notwithstanding any inconsistent statement in the
policy to which this endorsement is attached or any endorsement now or hereafter attached
thereto, it is agreed as follows:

1.    ADDITIONAL INSURED. The Los Angeles Community College District, its governing
      body, officers, agents, employees, representatives, and volunteers are included as
      additional insureds with regard to liability and defense of claims arising from the operation,
      use, occupancy or work performed by or on behalf of the named insured regardless of
      whether liability is attributable to the named insured or a combination of the named and
      the additional insured.

2.    APPLICABILITY. This insurance pertains to the operation and/or tenancy of the named
      insured under all written agreements in force with the Los Angeles Community College
      District (hereinafter referred to as LACCD) unless checked here in which case only the
      following specific agreement(s) with LACCD are covered:
                                                                        ____________

3.    CANCELLATION NOTICE. With respect to the interests of LACCD, this insurance shall
      not be canceled, materially reduced in coverage or limits, or non-renewed except after
      thirty (30) days’ prior written notice by receipted delivery has been given to LACCD.

4.    WAIVER OF SUBROGATION. The Company agrees to waive all rights of subrogation
      against LACCD, its governing body, the individuals thereof, and all officers, agents,
      employees, representatives, and volunteers for losses and expenses arising from the
      operation, use, occupancy, or work performed by the named insured in connection with
      the referenced agreement(s).

5.    OTHER PROVISIONS:
      a) Other Insurance
         This insurance coverage shall be primary insurance as respects LACCD, its
         governing body, the individuals thereof, and all officers, agents, employees,
         representatives, and volunteers. Any insurance or self-insurance maintained by
         LACCD shall be excess of this insurance and shall not contribute to it.
      b) Duties in the Event of Occurrence, Offense, Claim, or Suit
         Any failure by the named insured to comply with reporting provisions of this insurance
         shall not affect coverage provided to LACCD its governing body, the individuals
         thereof, and all officers, agents, employees, representatives, and volunteers.
      c) Separation of Insureds
         This insurance shall apply separately to each insured against whom claim is made or
         suit is brought, except with respects to the limits of this policy.




Form PA-0058                                     Page 4 of 12                            Rev.1-08.25.03
                      LO S AN G EL E S CO M M UN IT Y CO LL EG E D I S T RICT
                          DEPARTMENT OF FACILITIES PLANNING AND DEVELOPMENT
                                      PROPOSITION A/AA BOND PROGRAM




6. Type of Coverage                    7. Limits of Liability                8. Policy Period
   Occurrence                               Per Accident             From                  To
   Claims Made                              Each Occurrence
   Retroactive Date                         Aggregate
9.    Deductible       Self-Insured Retention of $       with an aggregate of                   applies to
      coverage      Per Claim      Per Occurrence


10. INCLUDES (check as applicable):
    Broad Form Liability Endorsement             Independent Contractors           Products/Completed
    Broad Form Property Damage                   Medical Payments                  Operations
    Contractual Liability                        Personal Injury and               Sexual Molestation
    Fire Legal Liability                         Advertising Injury                Owned Automobiles
    Incidental Medical Malpractice               Premises and Operations           Non-Owned
                                                                                   Automobiles
                                                                                   Hired Automobiles
11. Named Insured and Address

12. Name of Insurance Company and Address

13. Policy Number               14. This Endorsement No.           15. Effective Date of This Endorsement

16. Name of Claims Administrator         17. Mailing Address                            18. Phone No.


19. MAILING ADDRESS.
Completed endorsements and cancellation notice will be issued to LACCD addressed as
follows:
                         DMJM/JGM Program Management
                              Los Angeles Community College District
                                Proposition A & AA Bond Program
                                 Attention: Francine Gonzalez
                              515 South Flower Street, Ninth Floor
                                 Los Angeles, CA 90071-2201


20. I,                                           , (type or print name) hereby declare under
    penalty of perjury, under the laws of the State of California, that I am an underwriter
    employed by the above-named insurance company and that I have the authority to bind the
    above-named insurance company to this endorsement and by my execution hereof, do so
    bind said company.



                                                                                 _________________
                                                 Signature of Insurance Company Underwriter
                                                      (original signature only; no facsimile
                                                   signature or initialed signature accepted)



Form PA-0058                                        Page 5 of 12                            Rev.1-08.25.03
               LO S AN G EL E S CO M M UN IT Y CO LL EG E D I S T RICT
                  DEPARTMENT OF FACILITIES PLANNING AND DEVELOPMENT
                            PROPOSITION A/AA BOND PROGRAM




Executed at                                  ,                             on
         ,
200 .

                                                            Phone No.: (    )       -




Form PA-0058                            Page 6 of 12                            Rev.1-08.25.03
                      LO S AN G EL E S CO M M UN IT Y CO LL EG E D I S T RICT
                          DEPARTMENT OF FACILITIES PLANNING AND DEVELOPMENT
                                      PROPOSITION A/AA BOND PROGRAM




        WORKERS’ COMPENSATION AND EMPLOYERS LIABILITY ENDORSEMENT


In consideration of the premium charged and notwithstanding any inconsistent statement in the
policy to which this endorsement is attached or any endorsement now or hereafter attached
thereto, it is agreed as follows:

1. APPLICABILITY. This insurance pertains to the operations and/or tenancy of the named
   insured under all written agreements in force with the Los Angeles Community College
   District, (hereinafter referred to as LACCD) unless checked here  in which case only the
   following specific agreement(s) with LACCD are covered:
                                                                ____________

2. CANCELLATION NOTICE. With respect to the interests of LACCD, this insurance shall not
   be cancelled, materially reduced in coverage or limits, or non-renewed except after thirty (30)
   days’ prior written notice by receipted delivery has been given to LACCD.

3.    WAIVER OF SUBROGATION. The Company agrees to waive all rights of subrogation
     against LACCD, its governing body, the individuals thereof, and all officers, agents,
     employees, representatives, and volunteers for losses and expenses arising from the
     operation, use, occupancy, or work performed by the named insured in connection with the
     referenced agreement(s).

 4. TYPE COVERAGE                      5. LIMITS OF LIABILITY             6. POLICY PERIOD

          Part One                        Statutory                           From          To

          Part Two                        $        Each Accident              From          To

          Bodily Injury by Accident       $        Per Policy Limit

          Bodily Injury by Disease        $        Each Employee

          Bodily Injury by Disease

 7. INCLUDES (check as applicable)
        Broad Form All State Endorsements
        Voluntary Compensation
        Other

 8. Named Insured and Address

 9. Name of Insurance Company and Address

 10. Policy Number              11. This Endorsement No.         12. Effective Date of This Endorsement

 13. Name of Claims Administrator        14. Mailing Address                         15. Phone No.




Form PA-0058                                      Page 7 of 12                             Rev.1-08.25.03
                     LO S AN G EL E S CO M M UN IT Y CO LL EG E D I S T RICT
                         DEPARTMENT OF FACILITIES PLANNING AND DEVELOPMENT
                                  PROPOSITION A/AA BOND PROGRAM




16. MAILING ADDRESS. Completed endorsements and cancellation notice will be issued to
    LACCD addressed as follows:

                             DMJM/JGM Program Management
                             Los Angeles Community College District
                               Proposition A & AA Bond Program
                               Attention: Francine Gonzalez
                            515 South Flower Street, Ninth Floor
                               Los Angeles, CA 90071-2201


17. I,                                                     , (type or print name) hereby declare
    under penalty of perjury, under the laws of the State of California, that I am an underwriter
    employed by the above-named insurance company and that I have the authority to bind the
    above-named insurance company to this endorsement and by my execution hereof, do so
    bind said company.


                                                                              _________________
                                              Signature of Insurance Company Underwriter
                                                   (original signature only; no facsimile
                                                signature or initialed signature accepted)



Executed at                                          ,                               on
         ,
200 .

                                                                      Phone No.: (    )       -




Form PA-0058                                    Page 8 of 12                              Rev.1-08.25.03
                      LO S AN G EL E S CO M M UN IT Y CO LL EG E D I S T RICT
                          DEPARTMENT OF FACILITIES PLANNING AND DEVELOPMENT
                                       PROPOSITION A/AA BOND PROGRAM


               COMMERCIAL PROPERTY – LOSS PAYABLE ENDORSEMENT


In consideration of the premium charged and notwithstanding any inconsistent statement in the
policy to which this endorsement is attached or any endorsement now or hereafter attached
thereto, it is agreed as follows:

1. LOSS PAYEE. Loss or damage, if any, under this policy, shall be adjusted with the named
   insured and shall be paid, where applicable, to the named insured and the Los Angeles
   Community College District in whatever form or capacity their interests may appear.

2. APPLICABILITY. This insurance pertains to the operations and/or tenancy of the named
   insured under all written agreements in force with the Los Angeles Community College
   District, (hereinafter referred to as LACCD) unless checked here  in which case only the
   following specific agreement(s) with LACCD are covered:
                                                                ____________

3. CANCELLATION NOTICE. With respect to the interests of LACCD, this insurance shall not
   be cancelled, materially reduced in coverage or limits, or non-renewed except after thirty (30)
   days’ prior written notice by receipted delivery has been given to LACCD.

4. WAIVER OF SUBROGATION. The Company agrees to waive all rights of subrogation
   against LACCD, its governing body, the individuals thereof, and all officers, agents,
   employees, representatives, and volunteers for losses and expenses arising from the
   operation, use, occupancy, or work performed by the named insured in connection with the
   referenced agreement(s).

5. Type of Coverage                  6. Limits of Liability                 7. Policy Period
                                                               From                       To
8.    Deductible         Self-Insured Retention (check which applies) of $                      to
   coverage.     Per Claim      Per Occurrence      Per Loss

9. INCLUDES (check as applicable):
        Cause of Loss (check as applicable):                  Earthquake (Deductible:           )
        Basic                                                 Flood (Deductible:      )
        Broad                                                 Sprinkler Leakage
        Special                                               Other
        Other

10. Named Insured and Address

11. Name of Insurance Company and Address

12. Policy Number                        13. This Endorsement No.         14. Effective Date of This Endorsement

15. Name of Claims Administrator     16. Mailing Address                                       17. Phone No.




Form PA-0058                                           Page 9 of 12                                  Rev.1-08.25.03
                    LO S AN G EL E S CO M M UN IT Y CO LL EG E D I S T RICT
                       DEPARTMENT OF FACILITIES PLANNING AND DEVELOPMENT
                                 PROPOSITION A/AA BOND PROGRAM


18. MAILING ADDRESS. Completed endorsements and cancellation notice will be issued to
    LACCD addressed as follows:


                           DMJM/JGM Program Management
                           Los Angeles Community College District
                             Proposition A & AA Bond Program
                              Attention: Francine Gonzalez
                           515 South Flower Street, Ninth Floor
                              Los Angeles, CA 90071-2201

19. I,                                           , (type or print name) hereby declare under
    penalty of perjury, under the laws of the State of California, that I am an underwriter
    employed by the above-named insurance company and that I have the authority to bind the
    above-named insurance company to this endorsement and by my execution hereof, do so
    bind said company.


                                                                            _________________
                                            Signature of Insurance Company Underwriter
                                                 (original signature only; no facsimile
                                              signature or initialed signature accepted)



Executed at                                         ,                              on
         ,
200 .

                                                                    Phone No.: (    )       -




Form PA-0058                                  Page 10 of 12                             Rev.1-08.25.03
                      LO S AN G EL E S CO M M UN IT Y CO LL EG E D I S T RICT
                          DEPARTMENT OF FACILITIES PLANNING AND DEVELOPMENT
                                    PROPOSITION A/AA BOND PROGRAM




                         PROFESSIONAL LIABILITY ENDORSEMENT


In consideration of the premium charged and notwithstanding any inconsistent statement in the
policy to which this endorsement is attached or any endorsement now or hereafter attached
thereto, it is agreed as follows:

1. APPLICABILITY. This insurance pertains to the operations and/or tenancy of the named
   insured under all written agreements in force with the Los Angeles Community College
   District, (hereinafter referred to as LACCD) unless checked here  in which case only the
   following specific agreement(s) with LACCD are covered:
                                                                ____________

2. CANCELLATION NOTICE. With respect to the interests of LACCD, this insurance shall not
   be cancelled, materially reduced in coverage or limits, or non-renewed except after thirty (30)
   days’ prior written notice by receipted delivery has been given to LACCD.

3. WAIVER OF SUBROGATION. The Company agrees to waive all rights of subrogation
   against LACCD its governing body, the individuals thereof, and all officers, agents,
   employees, representatives, and volunteers for losses and expenses arising from the
   operation, use, occupancy, or work performed by the named insured in connection with the
   referenced agreement(s).
4. Type of Coverage                   5. Limits of Liability              6. Policy Period
                                                                      From              To
7.      Deductible    Self-Insured Retention (check which applies) of $            applies to
     coverage.
        Per Claim     Per Occurrence        Per Incident
8. Named Insured and Address

9. Name of Insurance Company and Address

10. Policy Number              11. This Endorsement No.           12. Effective Date of This Endorsement

13. Name of Claims Administrator   14. Mailing Address                                   15. Phone No.



16. MAILING ADDRESS. Completed endorsements and cancellation notice will be issued to
    LACCD addressed as follows:

                                     DMJM/JGM Program Management
                                    Los Angeles Community College District
                                      Proposition A & AA Bond Program
                                       Attention: Francine Gonzalez
                                    515 South Flower Street, Ninth Floor
                                       Los Angeles, CA 90071-2201




Form PA-0058                                      Page 11 of 12                              Rev.1-08.25.03
                    LO S AN G EL E S CO M M UN IT Y CO LL EG E D I S T RICT
                       DEPARTMENT OF FACILITIES PLANNING AND DEVELOPMENT
                                 PROPOSITION A/AA BOND PROGRAM




17. I,                                           , (type or print name) hereby declare under
    penalty of perjury, under the laws of the State of California, that I am an underwriter
    employed by the above-named insurance company and that I have the authority to bind the
    above-named insurance company to this endorsement and by my execution hereof, do so
    bind said company.



                                                                            _________________
                                            Signature of Insurance Company Underwriter
                                                 (original signature only; no facsimile
                                              signature or initialed signature accepted)



Executed at                                        ,                            on
         ,
200 .

                                                                 Phone No.: (    )       -




Form PA-0058                                 Page 12 of 12                           Rev.1-08.25.03

				
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