CSRMA POLICY & PROCEDURE MEMORANDUM # 9-L Subject: RESIDENTIAL

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CSRMA

POLICY & PROCEDURE

MEMORANDUM # 9-L

Subject: RESIDENTIAL SEWER BACKUP RESPONSE AND CLAIMS

HANDLING

Effective: August 17, 2007

PURPOSE

This Policy and Procedure (Policy) is intended to provide protocols for Members of the

Pooled Liability Program (Program) that operate sanitary sewer collection systems. Its

purpose is to assist Members Agencies to respond effectively to residential sewer backup

incidents, properly perform their responsibilities in the resolution of any resultant claims,

and to minimize the cost of any claim.

POLICY

Sewer backups into homes and businesses are one of CSRMA’s greatest general liability

exposures. Effective risk management following a sewer backup event requires

preplanning and coordinated efforts between the:

• Member Field Staff

• Member Administrative Staff (referred hereafter to as the Members’ “Claims

Management Coordinator”)

• Emergency Restoration Services Contractor (or other construction, and/or

restoration management service providers)

• CSRMA Claims Administrator (Carl Warren & Company)

Sewer backups will occur occasionally; this Policy has been enacted to facilitate

preplanning and a coordinated response between the Member, any outside contractors

and the CSRMA Claims Administrator. Each party has a specific role to play, and the

failure of any party to carry out their responsibilities can negatively affect the resolution

of an incident or claim.

It is the intention of CSRMA, through this Policy (and other Member agreements) to

assist Members to handle claims effectively and to contain costs.



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PROCEDURE

Each Member is responsible for adopting its own “Sewer Backup Response & Claims

Handling Policy & Procedure” (“Member Policy”). All sewer backup incidents and any

resulting claims shall be processed in accordance with the Member’s Policy.

The Member Policy must include (conform to) at least the following key elements:

1. Identify a person to serve as CSRMA’s “Claims Management Coordinator”. The

employee filling this position will serve as the key contact on sewer back-up

incidents between the Member, and Carl Warren and Co. The employee will also

serve to coordinate any communication between any third party vendors and the

affected individuals of any residence.

2. The “Claims Management Coordinator” shall have the authority to act on the

Member’s behalf to deliver necessary emergency services to mitigate any

damage, or resultant cost, of any incident.

3. All Member employees that respond to sewer backup incidents shall attend a

CSRMA sponsored or approved “Sewer Backup Response & Claims Handling”

training seminar on a three year revolving schedule.

4. The Members identification of multiple local emergency restoration firms

qualified to respond to incidents. These vendors are to be qualified using the

“CSRMA Water Damage Restoration Firm Screening Tool”. The Member shall

have met with representatives from each vendor and determined in advance what

activities constitute authorized “Emergency Services” for sewer backup incidents.

Any services needed or desired beyond those identified as “Emergency Services”

are to be authorized only by Carl Warren & Co.

5. The Members’ identification of multiple local hotels, motels, or alternative

housing for the provision of emergency alternate living arrangements for affected

individuals. Pre-arranged terms between the Member and such facilities shall be

agreed to minimize confusion over acceptable charges. A standard “Hotel

Authorization Form” for the residential customer to sign acknowledging the terms

and conditions under which emergency alternate living arrangements are granted

shall be developed and provided to the customer when needed.

6. The Member shall first take the necessary time to identify the cause and

responsibility for the sewer back-up and then notify Carl Warren & Company

within four hours of any incident that may be the responsibility of the Member.

Upon notification, the Claims Management Coordinator and Carl Warren will

jointly determine if the incident is likely to result in a claim against the Member.

If so, Carl Warren & Company will assume management of the incident response.



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The purpose of this notice requirement is not to give Carl Warren control over the

conduct of Member employees, but instead to assure that Carl Warren is involved

in decisions relating to the retention, scope of work, and compensation of any

outside contractors, and to give Carl Warren adjusters the ability to consult with

the Member concerning factual investigation relating to potential liability and

damages at the earliest time feasible.

7. The Member shall have a written procedure governing the distribution and

processing of Claim Forms. If requested by a party affected by a sewer back-up,

Member staff must provide a Claim Form, or must provide information about

how to obtain a Claim Form, or how to make a claim. The procedure must

ensure that Carl Warren and Company is notified when a claim form is provided.

Any claim may later be rejected if a subsequent investigation into the cause of the

loss indicates the Member was not responsible for the incident, or if the claim is

made improperly.

8. Each Member will submit all incident and/or documentation materials in a timely

manner to Carl Warren & Company. Claim Forms should be submitted within

one business day of receipt.

9. It is the responsibility of each Member to direct all claimant concerns and

questions regarding the adjustment of their claim to the Carl Warren & Company

Claims Adjustor, or to the CSRMA Program Administrator.

PROVISIONS FOR NON COMPLIANCE

If, during the resolution of any claim, it becomes apparent that either the Member has not

adopted its own Member Policy for managing sewer backup incidents and claims in

accordance with this Policy, or has not followed its Member Policy and either failure has

exacerbated the settlement of the claim, or resulted in an increased cost of the claim, a

review of the failure (audit) will be triggered. The audit will be performed by CSRMA,

or its designee.

The purpose of the audit will be to determine the cause of the failure and to recommend a

correction. The results of the audit will be reported to the Pooled Liability Program

Committee and to the Member. If the source of the failure cannot be corrected, the

failure and recommended correction will be scheduled for discussion and possible action

at a Pooled Liability Program Committee meeting. The cost of the audit, if any, will be

borne by the Member.

TIME FRAME FOR COMPLIANCE

All Members to which this Policy applies are to be in compliance with this Policy within

six months of adoption by the CSRMA Board of Directors, or within six months of

having joined the Program.



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SAMPLE DOCUMENTS

The documents referenced in this Policy and other materials related to managing sewer

backup claims can be found in the Pooled Liability Program Manual. These are as

follows, and are located in Section General Claims Information (Tab L2), Forms (Tab J).

A. CSRMA Sewer Backup Response & Claims Handling Policy & Procedure

Schematic

B. Sewer Back-Up Incident Report

C. Livability Assessment Schematic

D. Customer Information Regarding Sewer Backup Claims (Letter)

E. Sewer Spill Reference Guide - Your Responsibilities as a Private Property Owner

F. CSRMA Water Damage Restoration Firm Screening Tool

G. Sewer Ordinance Recommended Considerations

H. Sample Hotel Authorization Form

I. Release Of All Claims for Sewer Back Up

J. Claims Submittal Checklist

CSRMA Sewer Backup Response & Claims Handling Policy & Procedure

1. Consider adopting Backwater Prevention Device requirements in the Agency’s Sewer Use Ordinance

2. Identify multiple local emergency restoration firms

Qualify these vendors using the CSRMA Water Damage Restoration Firm Screening Tool

Meet with representatives from each vendor and authorize emergency services only until Carl Warren

& Co. authorizes additional services

3. Identify multiple local hotels for emergency alternate living arrangements

Develop standard agreement for customer to sign acknowledging terms/conditions emergency

alternate living arrangements are granted

Establish billing agreement with each hotel

4. Customize the CSRMA Customer Information Letter Following a Sewer Backup to their Agency

5. Identify at least 2 Field Points of Contact at the Agency

Provide training for these persons on the CSRMA Sewer Backup & Claims Handling P&P

Provide authority for authorizing emergency alternate living arrangements

Develop mechanism for Field Crews to determine when these persons are to be contacted to come to

scene and assume control

Provide training for these persons on how to review/approve scope of emergency services

6. Develop Field Response Procedures for Field Crews that are in accordance with this P&P

Provide training to Field Crews on the Agency’s Sewer Backup Emergency Response Plan

Provide training to Field Crews on how to make initial determinations of responsibility

Provide training to Field Crews on documenting initial determinations of responsibility (esp.

photographic evidence)

7. Identify at least 2 persons at the Agency who are responsible for communicating with Carl Warren & Co. on

sewer backup claims mgt issues

Provide the contact information for these persons to Carl Warren & Co.

Provide training for these persons on this P&P

Ensure these persons and Carl Warren & Co. have met/spoken

8. Develop an internal mechanism to ensure Carl Warren & Co. is notified with 4 hours of all sewer backups

where the Agency may have responsibility

9. Ensure all Agency vehicles that could respond to a sewer backup are equipped with cameras

10. Ensure the Agency has a mechanism to ensure sewer backup calls are addressed 24/7

Prior to Event, Member Mgt shall implement the following:

1. Initiate contact with the Customer & provide the following:

Agency Claim Form, or instructions on how to obtain a claim form

Sewer Backup Customer Information Letter

Hotel Authorization, as necessary

2. Explain to the Customer that your Agency has authorized payment for emergency services only & that all future

expenses &/or questions regarding claims issues must be discussed with Carl Warren & Co.

3. Complete the Sewer Backup Summary Report

4. Review the scope of emergency services proposed by the restoration firm

5. Immediately contact Carl Warren & Co. & provide the following information:

Customer contact information

Extent of the backup

Scope of services proposed by the restoration firm

NOTE 1: If Carl Warren & Co. can’t be immediately reached, use best professional judgment to determine if the

scope of services proposed by the restoration firm is appropriate. If in doubt, limit the scope of services to that

which seems reasonable until Carl Warren & Co. can be reached.

Note 2: If the severity of the backup is beyond your ability to manage, request Carl Warren & Co. provide a Field

Examiner ASAP.

6. Collect the camera used by the Field Crew & take additional photos, as necessary

7. Gather all evidence/documentation of the following:

Cause of the backup Extent of the damages caused by the backup

8. Forward all photos, completed Sewer Backup Summary Report & other documentation/evidence to the Claims

Management Coordinator.


Agency is Notified of a Sewer Backup Event

Does The Backup Appear To Be As A Result Of A Failure In The Agency’s Sewer Lines?

Agency Field Crew Respond & Make Initial Determination of Responsibility

YESNO

Agency Field Point of Contact Performs the Following:

1. Relieve the cause of the backup

2. Advise the customer to keep all family members/pets out of any

contaminated areas

3. Notify Agency Field Point of Contact of the incident (if not already

on the scene) & request permission to call out one the Agency’s

pre-approved restoration firms

4. If permission was granted, contact one the Agency’s pre-

approved restoration firms & request a crew be dispatched

5. Notify customer that an Agency representative (if not already on

the scene) & that a restoration crew will arrive shortly

6. Take photos of affected & non-affected areas on the property

7. Follow the Agency’s SSO Emergency Response Plan, as

necessary, until either the restoration crew or the Agency Field

Point of Contact arrives

8. If the restoration firm arrives before the Agency Field Point of

Contact, authorize only emergency cleaning services (i.e. no

demolition)

Agency Field Crew Perform the Following:

1. Inform Owner/Tenant the cause of the

backup is not in the Member owned

sewer lines and that the Member is not

responsible for private service lines.

2. Document all evidence (photos, diagrams,

narrative, etc) that the backup is not due

to a failure in the Agency’s sewer lines

Agency Field Crew Perform the

Following:

Go to Side 2

Carl Warren & Company

Tel (888) 542-8001

Fax (925) 825-5964

P.O. Box 3975

Walnut Creek, CA 94598

Sample Attachment A


1. Initiate contact with Owner/Tenant as soon as possible, but no later than the first business day after

notification of the loss

2. Make all necessary arrangements for lodging, food and incidentals beyond those made by the Agency

immediately following the loss

3. Negotiate & oversee the restoration firms’ work to ensure proper scope of cleaning, disinfection, &

demolition

4. Investigate, adjust and administer claim to closure

5. Whenever prudent to do so, have claimant agree, as a condition of claims settlement, to install and

maintain, at their expense, a Backwater Prevention Device meeting local requirements on their service

lateral

6. For claims where the estimated settlement timeframe is greater than 30-days, provide the Agency’s Claims

Management Coordinator with status reports bi-weekly, as necessary or as requested by the Claims

Management Coordinator.

7. For claims with issues complicating movement towards settlement, immediately notify the CSRMA Program

Administrator’s for guidance

8. When circumstances warrant or when requested, dispatch a Field Adjustor to the location of the sewer

backup

Carl Warren & Co. Perform The Following:

Start Here From Side 1

1. Review the Sewer Backup Summary Report, photos taken & all other documentation/evidence provided by

the Agency Field Point of Contact

2. Set up a claims file and insert copies of all relevant information

3. Immediately contact Carl Warren & Co. & discuss the following:

Documentation gathered

Plan of action

Alternate living arrangements, if necessary (ensure Carl Warren & Co. assumes responsibility for

managing alternate living arrangements/incidentals from this point forward)

4. Document the date, time & content of the discussion with Carl Warren & Co. and place in the claim file

(NOTE: document all phone conversations/other communication with the Customer & Carl Warren & Co.

from this point forward & keep in the claim file)

5. Immediately forward the Sewer Backup Summary Report, photos and all other relevant

evidence/documentation gathered to Carl Warren & Co.

6. Direct all Customer concerns and questions regarding the adjustment of their claim to the Carl Warren &

Co. Claims Adjustor or Account Manager or to the CSRMA Program Administrators

7. Communicate with the Claims Adjustor and/or Account Manager bi-weekly or as necessary to keep

informed of the status of the claim and provide information, as necessary

8. Ensure the Claims File is kept current with all communications between Carl Warren & Co., the Customer,

the restoration firm and other involved parties

9. Provide internal status reports, as necessary, to appropriate members of management staff

Agency “Claims Management Coordinator”

Carl Warren & Company

Tel (888) 542-8001/ Fax (925) 825-

5964

P.O. Box 3975

Walnut Creek, CA 94598

Sample Attachment A

GO TO SIDE 2

Sewer Backup Incident/Claim Report

Prepared by David Patzer,707.373.9709

Copyright 2004

IS NEAREST UPSTREAM MANHOLE VISIBLY HIGHER THAN THE DRAIN THAT OVERFLOWED? Yes No

# OF PEOPLE LIVING AT RESIDENCE:

DAMAGE: Toilet Bowl Water Sewage Grey Water Other (describe):_______________________________

SUSPECTED CAUSE OF FLOODING: Blockage Infrastructure Failure Inflow Infiltration Power Failure

Capacity Deficiency Natural Disaster Bypass Cause Unknown

- If spill caused by Blockage, please specify: Roots Grease Debris Debris from Laterals Vandalism

Animal carcass Construction Debris Multiple Causes

- If Blockage caused by Roots, please specify the following: Location:

_______________________________________

Source of Roots appear to be from: Lateral Explain ______________________________________________

Main Explain _______________________________________________

Uncertain

Severity of Roots: Light Medium Heavy

- If Blockage caused by Debris from Lateral or Construction Debris, please specify the following:

Location:

____________________________________________________________________________________

Describe the Material:

__________________________________________________________________________

Suspected Source of Material:

___________________________________________________________________

- If spill caused by Infrastructure Failure, please specify: Breakage of collection system

Damage to collection system Leaks to collection system Pump station failure Multiple causes

- Specify Other Cause:

____________________________________________________________________________

STREET ADDRESS:

CITY, STATE AND ZIP:

PHONE:

STREET ADDRESS:

CITY, STATE AND ZIP:

PHONE:

PROPERTY MANAGERS:RESIDENT:

EMPLOYEE NAME:DATE OF INCIDENT: TIME:

SECTION A

TIME STAFF ARRIVED ON-SITE: ___________ DID CUSTOMER CALL CLEANING CONTRACTOR? Yes No

IF YES, WHO & WHEN?

____________________________________________________________________

Yes No UnknownHave there ever been any previous spills at this location?

Yes No

Yes No

Does the Customer have a Backwater Prevention Device?

If yes, was the device operational at the time of the overflow?

Digital or Film? __________Numbers of Pictures Taken: ____________

Approximate age of home: _______ # of Bathrooms: _______ # of Rooms Affected: _______

Approximate Amount of Spill: _____ gallons Approximate Time Sewage Has Been Sitting: _____ hrs/days

How Was Spill Volume Calculated?:

Has the Resident Had Any Plumbing Work Done Recently? Yes No If Yes, please describe:

Sample Attachment B

Company Name: _____________________ Phone: ______________ Arrival Time: ____________________

Comments:

_____________________________________________________________________________________

SECTION D CLEANING CONTRACTOR

SECTION C SANITARY SEWER LINE BLOCKAGE LOCATION

SECTION B LIVABILITY ASSESSMENT

Is it after 8pm or will the cleaning &

disinfection be completed after 10pm?

Is there a functioning and non-

contaminated bathroom available?

Is area a child or extended care facility?

STOP – Resident Can Stay In Premises

Is food prep. area contaminated?

Any residents that:

1. Are pregnant?

2. Have severe allergies/asthma?

3. Have respiratory problems?

4. Have a compromised immune system?

Is there sufficient non-contaminated living

space for residents to stay during cleaning ?

NO

YES

YES

YES

YES

YES

YES

NO

NO

Advise resident to vacate premises while area is cleaned & disinfected.

NO

NO

NO

PLEASE CHECK THE BOX THAT

DESCRIBES YOUR OBSERVATIONS

Empty

Full

Non-Existent

EmptyFullNon-

Existent

Agency Structure WasCustomer

Cleanout

Was:Affected

House

Upstream

House

Direction of Flow

Property Line

Manhole #

Place an X where the blockage occurred

Circle the areas where sewage overflowed/ backed-up

Recommended Follow-Up Action(s):

Manhole #

1. Recommend to resident they stay at a hotel

while the area is cleaned & disinfected

2. Review the Agency’s Hotel Selection

Form/Policy with resident

3. Explain that the Agency will pay for first night

of hotel lodging & that Carl Warren & Co. will

discuss additional nights lodging, food & other

necessities with them directly.

4. Follow your Agency’s procedures for

temporary alternate living arrangements

Is there a strong odor or do you get the

impression the customer would be happier

staying elsewhere during the cleaning?

YES

NO

Did sewage get under the building? Yes No Unknown

Sample Attachment C

<INSERT AGENCY NAME HERE>

Customer Information Regarding Sewer Backup Claims

Distribution Instructions – Top Copy To < INSERT AGENCY NAME HERE >; Middle Copy To TPA; Bottom Copy To Customer

Address:______________________________________________________________________________

Dear Mr./Mrs. ____________________________________ DATE: _____________________

We recognize that sewer back flow incidents can be stressful and require immediate response when all

facts concerning how an incident occurred are unknown. Rest assured that we do all we can to prevent this

type of event from occurring. Nevertheless, occasionally tree roots or other debris in the sewer lines can

cause a backup into homes immediately upstream of the blockage. At this time the <INSERT AGENCY

NAME HERE> is investigating the cause of this incident.

If the < INSERT AGENCY NAME HERE > is found to be responsible for the incident, we are committed to

cleaning and restoring your property, and to protecting the health of those affected during the remediation

process.

The cleaning contractor provided by the < INSERT AGENCY NAME HERE > has been selected because of

their adherence to established protocols that are designed to assure all parties thorough, cost-effective and

expeditious cleaning services. < INSERT AGENCY NAME HERE > will pay this cleanup contractor’s fee.

You also have the right to select your own cleaning contractor, but < INSERT AGENCY NAME HERE >

does not guarantee payment of these expenses and reserves the right to refuse or dispute any fees that are

not usual and customary.

The company assigned to manage the necessary cleaning and restoration process is ______, and you can

reach them directly at _______. It is possible however that other contractors may be involved in any

needed restoration service. Carl Warren and Company, noted below, has the final responsibility for

processing any claims for damages that are submitted.

If you wish to discuss this matter, or submit a claim for damages, please contact either of the following:

INSERT AGENCY POINT OF CONTACT HERE – PHONE – BUSINESS HOURS

Carl Warren and Company (Claims Administrator) : 888.542.8001

******************************************************************************************* What you need to do now:

< INSERT AGENCY NAME HERE > has prepared this brief set of instructions to help you minimize the

impact of the loss by responding promptly to the situation. Do not attempt to clean the area yourself, let the cleaning and restoration company assigned

handle this. Keep people and pets away from the affected area(s).

Do not remove items from the area – the cleaning and restoration company will handle this.

If you had recent plumbing work, contact your plumber or contractor and inform them of this incident.

If you intend to file a claim, do so as soon as practical –The California Government Code,

Sections 900 - 960, requires the filing of a written claim and outlines specific time lines and

notice procedures that must be used in order to have a claim considered.

******************************************************************************************* I/We acknowledge receipt of this letter.

Employee Signature: _________________________________ Date: ______________

Customer Signature: _________________________________ Date: ______________

Sample Attachment D

What is a Sewage Spill?Sewage spills occur when the wastewater being transported via underground pipes overflows through a manhole,

cleanout, or broken pipe. Sewage spills can cause health hazards, damage to homes and businesses, & threaten the

environment, local waterways, & beaches.

Common Causes of Sewage Spills:Grease builds up inside, and can eventually block sewer pipes. Grease gets into the sewer from food

establishments, household drains, as well as from poorly maintained commercial grease traps & interceptors.

Tree roots enter through broken/cracked lines and eventually block sewer pipes. Planting of trees and

shrubbery over sewer lines should be avoided as this increases the likelihood of root intrusion leading to

blockage problems.

Structure problems caused by deteriorating sewer pipes, broken/cracked pipes, missing or broken cleanout

caps, or undersized sewers can cause blockages.

Infiltration & inflow (I/I) impacts pipe capacity and is caused when groundwater or rainwater enters the sewer

system through pipe defects & illegal connections.

CAUTION! When trying to locate a sewer problem, never open manholes or other sewer structures. Due topotential life-threatening hazards, only public entity personnel are allowed open & inspect these structures.

Who’s Responsible for Sewer Repairs and Maintenance?Each home or commercial building has a separate connection to the public sanitary sewer main called a sewer lateral.

It is the property owner’s responsibility to maintain & repair their own sewer lateral from the house to the point of

connection with the public sanitary sewer line.

You Are Responsible for a Sewage Spill Caused by a Blockage or Break in Your Sewer Lines!Time is of the essence in dealing with sewage spills. You are required to immediately:

Control & minimize the spill. Keep spills contained on private property & out of gutters, storm drains, & public

waterways by shutting off or not using the water.

Use sandbags, dirt and/or plastic sheeting to prevent sewage from entering the storm drain system.

It is recommended that a plumbing professional be called for clearing blockages & making necessary repairs.

Plumbing contractors are listed in the yellow pages under “Plumbing Drain & Sewer Cleaning” or Sewer

Contractors”. If you hire a contractor, it’s recommended that you get estimates from more than one company.

Always notify your public sewer district of sewage spills. If the spill enters the storm drain also notify the Health

Care Agency. In addition, if it exceeds 1,000 gallons notify the Governor’s Office of Emergency Services. Refer

to the numbers listed on back of this page.

You Could Be Liable for Not Protecting the Environment!Allowing sewage from your home, business or property to discharge to a gutter or storm drain may subject you to

penalties &/or out-of-pocket costs to reimburse cities or public agencies for clean-up and enforcement efforts.

Local & state agencies have legal jurisdiction & enforcement authority to ensure that sewage spills are

remedied.

They may respond & assist with containment, relieving pipe blockages, and/or clean-up of the sewage spill,

especially if the spill is flowing into storm drains or onto public property.

A property owner may be charged for costs incurred by agencies responding to spills from private properties.

What to Look For:Sewage spills can be a very noticeable gushing of water from a manhole or a slow water leak that may take time to be

noticed. Don’t dismiss unaccounted-for wet areas. Look for:

Drain backups inside the building.

Wet ground & water leaking around manhole lids onto your street.

Leaking water from cleanouts or outside drains

Unusual odorous wet areas: sidewalks, external walls, ground/landscape around a building.

Caution!Keep people and pets away from the affected area. Untreated sewage has high levels of bacteria and may contain

disease carrying viruses. Always be sure to wear gloves whenever working around raw sewage & to wash your hands

when done.

Sewer Spill Reference Guide:

Your Responsibility as a Private Property Owner

Sewage spills can cause damage to the environment –

Help prevent them!

Sample Attachment E – Page 1

How a Sewer System WorksA property owner's sewer pipes are called service laterals & are connected to larger local main and regional trunk

lines. Service laterals run from the connection at the home to the connection with the public sewer (including the area

under the street). These laterals are the responsibility of the property owner & must be maintained by the property

owner.

Sewer Spill Reference Guide:

Your Responsibility as a Private Property Owner

Operation & maintenance of local & regional sewer lines are the responsibility of the Sewer Agency

<INSERT AGENCY NAME> ResponsibilitiesProtecting property & streets, the local storm drain system, sewage collection system & other public areas.

Collecting, treating, & disposing of wastewater.

<INSERT AGENCY NAME>:<INSERT AGENCY CONTACT INFO> (M-Th 8-5; F 8-4) & <INSERT AGENCY AFTER HOURS CONTACT INFO> (all otherhours)

<INSERT LOCAL POLLUTION PREVENTION PROGRAM NAME AND CONTACT INFO>:California Health and Safety Code, Sections 5410-5416 requires:

No person shall discharge raw or treated sewage or other waste in a manner that results in contamination, pollution, or a

nuisance.

Any person who causes or permits a sewage discharge to any state waters:

Must immediately notify the local health agency of the discharge.

Shall reimburse the local health agency for services that protect the public’s health & safety.

Who fails to provide the required notice to the local health agency is guilty of a misdemeanor & shall be punished

by a fine (between $500–$1,000) and/or imprisonment for less than one year.

Regional Water Quality Control Board: <INSERT CONTACT INFO>Requires the prevention, mitigation, response to and reporting of sewage spills.

California Office of Emergency Services: (800) 852-7550California Water Code, Article 4, Chapter 4, Sections 13268-13271 & California Code of Regulations, Title 23, Division 3,

Chapter 9.2, Article 2, Sections 2250-2260 require:

Any person who causes or permits sewage in excess of 1,000 gallons to be discharged to state waters shall immediately

notify the Office of Emergency Services.

Any person who fails to provide the notice required by this section is guilty of a misdemeanor and shall be punished by a

fine (less than $20,000) and/or imprisonment for not more than one year.

IF YOU HAVE A SEWAGE SPILL FROM YOUR PRIVATE SEWER LINE, CONTACT:

SAMPLE –

ENSURE THIS

DIAGRAM

ACCURATELY

RELFECTS YOUR

JURISDICTION

Sample Attachment E – Page 2

CSRMA Water Damage Restoration Firm Screening Tool

ISSUE: INSURANCE PROVISIONS WHEN USING WATER DAMAGE RESTORATION SERVICES

FOLLOWING A SEWER OVERFLOW INTO A HOME OR BUSINESS

DISCUSSION: As an operator of a sewage collection system, your Agency must be prepared to respond to

sewer overflows that occur inside a home or business. Part of this preparation involves identifying local

water damage restoration contractors that have the necessary training, equipment, experience and

insurance to perform the job in a manner that does not expose your Agency to increased risk. Because of

the tremendous cost and potential health risks incorrect water damage remediation techniques can cause, it

is imperative that your Agency only work with professionally trained and properly insured contractors. This

form is designed to assist you in identifying these water damage restoration contractors in your area.

REQUEST TO PROVIDE WATER DAMAGE RESTORATION SERVICES

Name of Company: ___________________________________ Phone: ____________________

Address: _____________________________________________________________________________

Years in Business: ______ Average Response Time: ______ # of Field Service Vehicles: ________

Please List Any Water Damage Restoration Protocols Your Firm Follows: _______________________

_____________________________________________________________________________________

Is Your Staff Trained & Equipped To Address Mold Prevention? [ ] Yes [ ] No

If Yes, Please Identify When This Training Was Provided and By Whom: ___________________________

_____________________________________________________________________________________

_____________________________________________________________________________________

Do You Have: (please check all that apply)

[ ] General Liability Insurance? Limits: ______ Is there a mold exclusion in your policy? [ ] Yes [ ] No

[ ] Mold Coverage? Limits: __________________________

[ ] Errors & Omissions Coverage? Limits: ___________________________

[ ] Workers’ Compensation Coverage?

Please Identify at Least 3 References That Have Used Your Services In The Last Year:

1. NAME: _______________________________________PHONE: _________________________

2. NAME: _______________________________________PHONE: _________________________

3. NAME: _______________________________________PHONE: _________________________

If your firm is placed on our callout list, we will require that you submit a Certificate of Insurance naming

<Insert Name> as the additional insured. Is this acceptable: [ ] Yes [ ] No

I Certify the Above is True and Correct:

____________________________________ ____________

NAME DATE

Sample Attachment F – Page 1

CSRMA Water Damage Restoration Firm Screening Tool

INSTRUCTIONS TO AGENCY

CSRMA recommends that your Agency not contract with any water damage restoration firm that:

Does not have general liability coverage with at least $1,000,000 limits

Does not have an average response time less than 1 hour

Does not have Workers’ Compensation coverage

Has been in business for less than 1 year

Has fewer than 2 field service vehicles

Has not provided mold remediation training to its staff in the last 2 years

Does not identify a recognized or industry accepted protocol for remediating water damage (i.e

IICRC S500, New York City Guidelines, other)

Cannot provide 3 references that have used their services in the last year

Cannot provide your Agency with a Certificate of Insurance naming your Agency as an additional

insured and otherwise complying with CSRMA’s “Insurance Requirements in Contracts” manual.

Sample Attachment F – Page 2

June 2004

CSRMA Risk Control RECOMMENDED SEWER USE ORDINANCE CONSIDERATIONS

CSRMA recommends that your Agency review the following and compare against your existing Sewer Use Ordinance requirements:

A. A Backflow Prevention Device shall be required when:

1. All new construction and side sewer replacements shall be equipped with a cleanout riser equipped with a backflow prevention device (BPD)

2. Where existing buildings have plumbing drain outlets at an elevation that is 12” or less above the ground surface of the next upstream manhole, the property owner shall have and maintain a BPD

3. Change of property title 4. Issuance of all building permits, residential building reports, revocable licenses, and other building-related

permits 5. On remodels where plumbing fixtures are added to the property, and/or more than twenty-five percent of

the structure area is being remodeled 6. When any replacement or repair is made to the sanitary sewer lateral 7. When property has been damaged by the blockage of the city sanitary sewer main or lateral 8. On all structures where a pump is used to lift sewage to the sanitary sewer lateral and city sanitary sewer

main. The backflow relief device shall be located to protect the structure from damage in the event the pump is pumping against a closed backflow prevention device

9. Buildings where the elevation of any floor is at or below the invert of the city sanitary sewer main, or where a condition exist where a plug in the city sanitary sewer main will cause the hydraulic grade line to rise above the lowest floor level.

B. The responsibility for the operation and maintenance of the building side sewer and its fittings/devices is the property owner’s

C. Failure of the owner to install a backflow prevention device for or as a result of any of the above conditions shall

relieve the District of any and all responsibilities for any and all subsequent damage caused by sanitary sewer flooding.

D. Property owners are responsible for proper installation and maintenance of building and lateral sewers and

cleanouts, and for obtaining the necessary construction and encroachment permits. E. Property owners are responsible for keeping the 3’ radius of the cleanout area clear of vegetation or any

obstruction for visibility and easy access.

For Sample Ordinance Language or Sample Ordinances,

Please Contact David Patzer, CSRMA Risk Control Advisor

at 707.373.9709 or [email protected]

Attachment G

SAMPLE HOTEL SELECTION FORMINSTRUCTIONS TO EMPLOYEE:1. Review this form with the customer and instruct them to read and select, in order of preference, which of the hotels

below they wish to stay at.

2. Call the hotels, in the order selected, to determine vacancy. Follow your Agency’s hotel payment procedures for

the selected hotel with vacancy.

3. Explain to customer that additional nights and other incidentals will be addressed by the<INSERT AGENCY RISK

MANAGER> or by Carl Warren and Co.

3. Instruct the customer that this emergency authorization is for LODGING ONLY – NO FOOD, MINIBAR, MOVIE,

PHONE or Other Charges).

4. Have the customer sign the Acknowledgement section of this form.

5. Complete the voucher information and sign. Please note that an unsigned voucher will not be honored at the

hotels.

6. Give the bottom copy of this form to the customer.

***************************************************************************************************************************************

INSTRUCTIONS TO RESIDENT: The <INSERT AGENCY NAME> recommends that you temporarily relocate to

one of the hotels listed below for your safety and convenience while your residence is being cleaned. Please note

that this emergency authorization is granted under the following conditions:

1. The voucher authorizes payment of one (1) night’s stay at one of the hotels listed below.

2. The voucher is good for room and tax ONLY. Phone, food, and other incidental charges will be your responsibility.

3. Additional nights/other allowances/incidentals may be discussed by contacting the <INSERT AGENCY RISK

MANAGER AT <PHONE>> or by Carl Warren and Co. at <PHONE>.

4. Please bring a photo ID with you so that hotel staff can verify the voucher’s authenticity.

**************************************************************************************************************************

*

CUSTOMER ACKNOWLEDGEMENT:I/we have read and understood the terms and conditions governing this offer of temporary relocation and agree to

abide by them as described above.

Customer Name (Please print) _____________________________________________________________________

Customer Address: ______________________________________________________________________________

Phone # Where Customer May Be Reached: __________________________________________________________

Customer Signature: __________________________________________________________Date:_______________

Hotel Staff: Please direct any questions regarding this voucher to the <INSERT AGENCY RISK MANAGER AT <PHONE>>

EMERGENCY HOTEL AUTHORIZATION VOUCHER

Good for one (1) night’s Stay on (date) __________ Other Guest Name(s): __________________________________

Field Supervisor Name: __________________________________ Phone #: ________________________________

Best Western John Muir Inn

445 Muir Station Rd, Martinez

925.229.1010

Lafayette Park Hotel

3287 Mount Diablo Blvd, Lafayette

925.283.3700

Residence Inn By Marriott

700 Ellinwood Way, Pleasant Hill

925.689.1010

Distribution Instructions – Top Copy To Agency Risk Mgr.; Middle Copy To Collections Mgr..; Bottom Copy To Customer

SAMPLE ONLY – PLEASE INSERT MAPS OF AGENCY HOTELS HERE

Sample Attachment H

California Sanitation Risk Management Authority

Rev. 03/26/07

RELEASE OF ALL CLAIMS FOR SEWER BACKUP LOSSES TO: ________________________________________________________

District Name

The undersigned, <insert name of claimants>, being of lawful age, for the sole consideration of <Insert sum of the settlement> to be paid to them by <Insert name of District> do jointly and severally, for themselves and for their

heirs, executors, administrators, successors and assigns releases, acquit and forever discharge <Insert name of District> and its officers, directors, employees, agents, servants and successors of and from any and all claims,

actions, causes of action, demands, rights, damages, costs, loss of service, expenses and compensation whatsoever,

which the undersigned now has or which may hereafter accrue on account of or in any way growing out of any and all

known and unknown, foreseen and unforeseen bodily and personal injuries and property damages and the

consequences thereof, resulting or to result from the accident, casualty or event which occurred on or about the

<Insert date of loss> at or near <Insert address of the loss>.

It is further understood and agreed that all rights under Section 1542 of the Civil Code of California and any similar law

of any state or territory of the United States are hereby expressly waived by the undersigned. Said section reads as

follows:

"1542. Certain claims not affected by general release. A general release does not extend to claims which the creditor

does not know or suspect to exist in his favor at the time of executing the release, which if known by him must have

materially affected his settlement with the debtor."

The undersigned hereby declare and represent that the damages and injuries sustained are or may be permanent and

progressive and that recovery there from is uncertain and indefinite, and in making this Release, it is understood and

agreed, that the undersigned relies wholly upon the undersigned's judgment, belief and knowledge of the nature,

extent, effect, and duration of said damages and injuries and liability therefore and is made without reliance upon any

statement or representation of the parties released or their representatives.

The undersigned further declare that they agree to install and maintain, at their expense, a sewer backflow prevention

device on their private service lateral meeting all local, State and Federal requirements, including those of <Insert name of District> at <Insert address of the loss>.

The undersigned agree that failure to install a backflow prevention device shall relieve <Insert name of District> of

responsibility or liability for any and all subsequent damage caused by sanitary sewer flooding or back-up that would

have been prevented had such a back-flow prevention device been installed.

The undersigned understand that they are solely responsible for the proper installation, operation and maintenance of

building side sewers, fittings and devices and for obtaining the necessary construction and encroachment permits.

The undersigned also understand that they are solely responsible keeping the 3’ radius of the cleanout area clear of

vegetation or any obstruction for visibility and easy access.

The undersigned further declare and represent that no promise, inducement or agreement not herein expressed in the

release, has been made to the undersigned, and that this Release contains the entire agreement between the parties,

and that the terms of this Release are contractual and not a mere recital.

THE UNDERSIGNED HAS READ THE ABOVE AND FULLY UNDERSTANDS IT TO BE A FULL AND FINAL RELEASE OF ALL CLAIMS.

Signed, sealed and delivered this day of , 20 .

Witness to Signature

Address of witness Signature

Witness to signature Signature

Address of witness

Attachment I

CSRMA Sewer Backup Claims Submittal Checklist

I. Documents Delivered to Carl Warren

Item Date

Sewer Backup Customer Information Letter (signed original) ___________

Sewer Backup Summary Report ___________

Hotel Selection/Authorization Form (if applicable) ___________

Lateral TV Report (if applicable) ___________

Customer Service Response Form (Agency Work Order Form) ___________

All Photos Taken (electronic or hardcopy) ___________

Any Other Information Pertaining to the Incident/Claim ___________

II. Documents Delivered to the Homeowner

Item Date

Claim form, or information about how to obtain a claim form ___________

Hotel Selection/Authorization Form (if applicable) ___________

Customer Information Regarding Sewer Back-up Claims, or ___________

Sewer Spill Reference Guide: Your responsibility as a private property owner

___________

Sample Attachment J