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OFFICE OF RISK MANAGEMENT INSURANCE SERVICES by ftz16498

VIEWS: 11 PAGES: 2

									George Tischler
Interim Chief Risk Officer

Robert Reider
Interim Director of Insurance

                                OFFICE OF RISK MANAGEMENT & INSURANCE SERVICES

                                    REQUEST FOR APPROVAL OF SPECIAL EVENT
Date: _______________

Type of Organization:
         □ LAUSD School or Office
         □ Non-LAUSD Event Sponsor (PTA, Booster Club...etc)
         □ Other (Outside Organization)

   Non-LAUSD entities and other third parties are required to provide proof of insurance
   prior to using any District facility or participating in a special event.

Individual or Organization Name: ____________________________________________________________________

Address: ________________________________________________________________________________________

Contact
Person:__________________________________________________________________________________________

Phone: (_________) _________________________________ Fax: (_________) ______________________________

E-mail:

Type of
Event/Contract/Lease:______________________________________________________________________________

Please check:                   □ Health Fair           □ Athletic Event   □ Alcohol available       □ Vendors
           □ Food/Concessions                   □ Parking Lot overflow     □ Animals         □ other: __________________
Date(s) of Event: ________________________________________________________ Event Time: ____________

School/Facility Name & Address: ____________________________________________________________________

________________________________________________________________________________________________

Anticipated Total Event Attendance per Day: [Participants, Spectators, Staff and Guests]:_______________________

Does your organization have General Liability Insurance?

□ YES (Please include a copy of the certificate)
□ NO (Do you plan to purchase coverage from a broker or would you like a quote from the District’s Special
       Events Liability Program? _______________________________________________________________ )

Have you contacted the Leasing & Asset Management Branch? (213) 241-6785:                    □ YES           □ NO

           PRINCIPAL SIGNATURE:                                                                          Date:

Have You Informed your Local District Coordinator? □ YES    □ NO
Date Contacted? _________________________ Method of Contact: Phone ____ FAX ____                         In Person _____

           ORMIS APPROVAL (Manager’s Signature):                                                           Date:

REV. 8/09
Form 0003 Risk Management
INSTRUCTIONS:
   1. Fill out the information above and return to Insurance and Risk Finance
                      FAX: (213) 241-8956 or (213) 241-8993)
   2. When applicable, please include a list of planned events and activities or a detailed agenda.
   3. Allow 3 – 5 business days to process the request. If we have additional questions, we will contact you by
      telephone or email.


                                      Please forward completed request to:
                                     Office of Risk Management & Insurance Services
                                      Los Angeles Unified School District
                                     333 South Beaudry Avenue, 28th Floor
                                             Los Angeles CA 90017
                                           Telephone (213) 241-3065
                                       http//Riskmanagement.lausd.net




REV. 8/09
Form 0003 Risk Management

								
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