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Revised 07/01/14

Liability Claims Procedures Manual

and Property Claims Procedures Manual

Revised 07/01/14

LIABILITY CLAIMS PROCEDURES MANUAL AND PROPERTY CLAIMS PROCEDURES MANUAL

TABLE OF CONTENTS

Introduction .................................................................................................................................... iii

Contacts............................................................................................................................................v

Liability Claims Procedures

Section A: Claim Reporting Instructions .............................................................................1

Section B: Claims Handling Procedures – Third Party Administrator ................................4

Section C: Settlement Authority Procedure .........................................................................5

Section D: Determination on Coverage Issues and Appeal Procedures ..............................6

Section E: Status of Claim Against District .........................................................................7

Section F: Other Coverage ...................................................................................................8

Section G: Claims Presentation Requirements ....................................................................9

Section H: Written Claim...................................................................................................11

Section I: Timeliness..........................................................................................................13 Section J: Rejection / Allowance of Sufficient and Timely Filed Claims .........................14

Section K: Late Claims ......................................................................................................17

Section L: Amendment of Claims......................................................................................21

Section M: Insurance / Joint Powers Authority .................................................................22

Exhibit L1: Report of Personal Accident ...........................................................................23

Exhibit L2: Letter to Claimant ...........................................................................................24

Exhibit L3: Notice of Insufficiency ...................................................................................25

Exhibit L4: Verified Claim Form ......................................................................................26

Exhibit L5: Notice of Return Without Action – Incorrect Filing ......................................28

Exhibit L6: Notice of Rejection of Claim ..........................................................................29

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Exhibit L7: Notice of Return Without Action – Late Claim .............................................30

Exhibit L8: Notice of Denial of Application to Present a Late Claim ...............................31

Exhibit L9: Notice of Action Granting Application to Present a Late Claim ....................32

Exhibit L10: Proof of Service by Mail ..............................................................................33

Exhibit L11: Notice of Denial of Application to Present a Late Claim Filed....................34 Over One Year After Accrual of the Cause of Action

Property Claims Procedures

Section A: Claims Reporting Instructions .........................................................................36

Section B: Claims Handling Procedures ............................................................................37

Section C: Determination on Coverage Issues and Appeal Procedures ............................41

Section D: Other Coverage ................................................................................................42

Section E: Forms ................................................................................................................43

Exhibit P1: Property Loss Notice ......................................................................................44

Exhibit P2: Automobile Loss Notice .................................................................................47

Exhibit P3: Acknowledgment of Loss ...............................................................................51

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INTRODUCTION

This manual has been prepared for the purpose of having uniform procedures in the reporting and handling of claims and losses of Member Districts of the JPA. The following pages will explain proper procedures for processing claim reports and related materials. Periodically, a page will be revised or information added. Upon distribution, each revision shall be substituted for the obsolete page(s). Please be sure that appropriate District personnel, such as Principals, Central Office Administrators, and Risk Management personnel are made aware of the instructions in this manual and know how and when to use the various forms. This will eliminate any unnecessary delay in reporting claims. Please have your staff report claims promptly and accurately as this can help control your District's losses. The Third Party Administrator (TPA) contracting with the VCSSFA for Liability, Property and Fire claims is YORK Risk Services Group, located at 1889 North Rice Avenue., Suite 100, Oxnard, CA 93036, (805) 288-4310. All correspondence should be sent to the following address:

YORK Risk Services Group P.O. Box 5980

Oxnard, CA 93031 FAX: (805) 981-1428

EMERGENCIES: Any incident involving death, serious injury or incidents with multiple claimants should be reported immediately. The call should be placed to the main switchboard at (805) 288-4310. The call must be clearly identified as an emergency which will trigger and immediate response from our on-call list of adjusters. The TPA maintains an answering service after normal business hours (to include weekends and holidays), and they must be notified immediately in cases of severe claims and/or large losses. That number is (805) 288-4310. Occasionally the TPA will learn of a certain incident by way of the local news media. If it is deemed necessary, an investigation will commence before being notified by the District.

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The contract with the TPA specifies that each member District shall immediately report all liability, property, and fire claims directly to the TPA at the above address. The following pages outline the specific reporting procedures to be followed by the District. Failure to follow this claims reporting procedure increases the possibility that a District will incur unnecessary costs in the investigation, litigation, and settlement of a particular claim. IMPORTANT NOTE: It is very important that each school employee be aware of the need to promptly and correctly report all accidents and incidents involving school activities or property. School employees should discuss the facts of the accident and incidents ONLY with the enforcement authorities, authorized representatives of the school District, and the TPA Claims Examiners. Before discussing any accidents or incidents with outside people, employees should verify their identity and ensure that the individual is an authorized representative, by a call to the TPA.

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v

CONTACTS

Ventura County Schools Self- Funding Authority Elizabeth Atilano, Executive Director 5189A Verdugo Way Camarillo, CA 93012 805.383.1969 805.383.1971 fax Claims Administrator YORK Risk Services Group, Inc. P.O. Box 5980 Oxnard, CA 93031 805.288.4310 805.981.1428 fax

Tom Baber, Vice President of Liability 916.746.8834 [email protected]

Robert Powers, Assistant Vice President of Liability 805.288.4301 [email protected]

Rose Mary Jimenez, Assistant Account Manager 805.288.4306 [email protected]

Nancy Fuller, Senior Adjuster 805.288.4305 [email protected]

Sam Eriz, Senior Adjuster 805.288.4303 [email protected]

Carrie Barton, Administrative/Claims Assistant 805.288.4308 [email protected]

Daniel Powers, Claims Assistant 805.288.4309 [email protected]

mailto:[email protected]







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Liability Claims Procedures

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LIABILITY CLAIMS PROCEDURES

SECTION A: CLAIM REPORTING INSTRUCTIONS

The Liability Claims procedure applies to any personal injury, death, or damage to personal property other than school property. Injuries and deaths arising out of automobile accidents are also included in this category. When there is a question about whether a claim is covered by the Liability Claim Procedure, please fill out the appropriate forms and follow the procedure, and/or contact the TPA. Determinations as to applicability of coverage will be made by the TPA Claims Examiner or the VCSSFA.

1. It is the responsibility of the District to ensure that a VCSSFA "Report of Personal

Accident" form (Exhibit L1) is completed and sent to the TPA. 2. The school employee who either witnesses the injury or is supervising at the time of the

injury should complete the "Report of Personal Accident" form. The injured party should not be the one completing this form!

3. A "Report of Personal Accident" form shall be filled out when an accident involves

bodily injury to a student, parent, visitor, or member of the public, and has occurred at a school facility or event.

4. This form shall be sent IMMEDIATELY to the TPA Claims Examiner in care of YORK

Risk Services Group, Inc. P.O. Box 5980, Oxnard, CA 93031. The district should NOT retain a copy for its file. NOTE: If other pertinent information becomes available later, send a supplemental report to the TPA Claims Examiner. NOTE: Please state on all supplemental reports that: "The following report is being prepared contemplating use by defense counsel and is considered privileged information."

5. For any SERIOUS or FATAL INJURY or ACCIDENT, IMMEDIATELY phone the

TPA Claims Examiner. DO NOT DELAY REPORTING! 6. Witnesses to Accidents or Injuries

Identification of witnesses is especially important in accidents or injuries involving students or other persons that occur on School District property, at School District functions, or off campus. Therefore, the school employee who witnesses an accident, or becomes aware of an incident, should immediately report the names of all witnesses. This information shall be forwarded to the District Offices, who in turn shall notify the Claims Examiner.

VCSSFA Liability Claims Procedures Fiscal Year 2014-2015

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7. Written Claims for Damages

In the event a written claim for damage is received by a School District, a copy of the written claim should be immediately sent to the TPA Claims Examiner. Do not wait for the Board of Trustees to take action on the claim since this may delay the investigation.

8. Lawsuits

If the School, District or a District Employee is served with a lawsuit (Summons & Complaint), forward it immediately to the TPA Claims Examiner. It is important to identify the name and title of the person served, date, and time service was made, and the location of where the service was received and whether service was by mail or in person. One copy of the lawsuit papers shall be retained in the School District's Business Office. Time is very important in processing lawsuits as Answers or Pleadings must be immediately filed with the Court. The TPA will retain defense attorneys recommended by the TPA and approved by the VCSSFA Executive Committee to represent the District's interests. The TPA is responsible for informing defense counsel of all VCSSFA policies and procedures for the conduct of litigation. When a lawsuit is filed and served, the District could encounter certain situations off which a few will be outlined:

a. The lawsuit could be served either personally or by mail as outlined previously. It

is important to identify the name, title of person served, date and time service was made, and where service was received. There is a 30-day period following the date of service in which to provide an Answer to the suit unless an extension of time is granted by the Plaintiff's attorney. If an Answer is not filed within 30 days after service, Plaintiff's attorney could seek a default and request the Court to enter judgment in Plaintiff's favor without the District having the opportunity to contest the claim.

b. Periodically, schools or Districts will be contacted by claims adjusters from firms

other than the VCSSFA's TPA. When this happens, they shall be referred to the TPA Claims Examiner or the Ventura County Schools Self-Funding Authority.

c. If and when a lawsuit is referred to a defense attorney, the District (i.e. school

employees), should cooperate in obtaining needed information. If any questions arise, contact the TPA Claims Examiner or the Ventura County Schools Self-Funding Authority.


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9. Making School Employees Aware

It is very important that each school employee be aware of the need to promptly and correctly report all accidents and incidents involving school activities or property. School employees should discuss the facts of accidents and incidents ONLY with law enforcement authorities, authorized representatives of the School District, and the TPA Claims Examiners. Before discussing any accident or incident with outside people, employees should verify their identity and ensure that the individual is an authorized representative by calling the TPA. In the event the District’s property is the alleged cause of an injury or incident, preservation of the evidence should be taken and the item should be stored in a secure area. An example of this would be a stretched S-hook of a swing seat that should be kept for inspection. If the physical condition of the premise is going to be altered, photograph the area from different angles to document the condition of the area before repairs are made. If you have any questions about this information, call the TPA claims examiner.


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SECTION B: CLAIMS HANDLING PROCEDURES THIRD PARTY ADMINISTRATOR

When the TPA Claims Examiner receives a claim report, he/she will determine how the claim is to be handled. Some matters can be handled from the office by phone and mail. Others may require further field investigation and/or personal handling. A Claims Examiner will review the claim and will send a form letter (Exhibit L2) back to the District indicating what should/will happen to the claim. If anyone is contacted by an adjuster stating that he/she represents the District, it can be quickly verified by a call to the TPA or the Ventura County Schools Self-Funding Authority. If the Accident Report does not indicate all the information necessary to determine the seriousness of the exposure, the TPA Claims Examiner may contact the appropriate District personnel so further information can be gathered to be able to make a proper evaluation. The TPA Claims Examiner will attempt to settle claims when liability is reasonably clear or it otherwise makes economic sense, within the settlement authority limit as extended by the VCSSFA Board of Directors. Any liability settlement over that authority must be approved in accordance with the procedures set forth under the section entitled "Settlement Authority Procedure".


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SECTION C: SETTLEMENT AUTHORITY PROCEDURE 1. It is Authority Policy that:

a. Only properly authorized payments shall be made to valid claimants or for expenses incurred in connection therewith for the amounts not to exceed the "draft authority" as defined in the Agreement between the VCSSFA and the TPA.

b. Only properly authorized payments are to be made for amounts not to exceed the

limits as authorized by the Board of Directors. c. All claim settlements greater than the Executive Director's authority are to be

approved by a quorum of the Executive Committee prior to disbursement. d. All claims disbursements are to be accurately recorded on a claims register.

2. Settlement Procedure:

a. The TPA shall be permitted to settle claims up to $5,000 except that the VCSSFA hereby reserves the right to require prior approval of proposed settlements of any claim without regard to the amount of the proposed settlement, if the VCSSFA determines that the claim is of a sensitive nature requiring such approval.

b. The TPA shall consult with the applicable Member District prior to settlement

negotiations. Member District's input is very important and shall be seriously considered. If there is a disagreement between the TPA and the District regarding the settlement, the Executive Committee will make a final determination regarding settlement.

c. The Executive Director shall be permitted to authorize claim settlement between

$5,000 and $25,000. The Executive Director shall consult with the applicable Member District prior to the settlement negotiations. In the absence of the Executive Director (in observance of the chain of command within the Executive Committee), a member of the Executive Committee will have settlement authority between the $5,000 and $25,000 level. Member Districts' input regarding the settlement is very important and shall be seriously considered. If there is a disagreement between the Executive Director or Executive Committee member and the District regarding the settlement, the Executive Committee will make a final determination regarding the settlement.

d. Claim settlements over $25,000 shall have the approval of a quorum (4 members)

of the Executive Committee.


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SECTION D: DETERMINATION ON COVERAGE ISSUES AND APPEAL PROCEDURES

All members must comply with the VCSSFA Dispute Resolution Process as outlined in the VCSSFA Liability Coverage Memorandum for the applicable covered year.


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SECTION E: STATUS OF CLAIM AGAINST DISTRICT

It is the intent of the VCSSFA to ensure that member Districts are kept fully informed as to the status of any liability claim against the District. Therefore, all correspondence related to the claim from the Administrator, the Authority, Legal Counsel or the District should be copied to all parties. All communications related to liability claims shall be with the District delegated VCSSFA Board Member. All correspondence related to litigation must be marked and maintained as "Confidential". Any breach of this procedure will be addressed as provided for in the Memorandum of Coverage and the Liability Coverage Memorandum. When a Member District, through its designated Board Member, requests extraordinary services from Defense Counsel, which exceed what is required in the normal course of litigation, any additional cost related to such services will be charged directly to and paid by the District. The designated Board Member will be notified when litigation involving his/her District is being discussed with defense counsel or otherwise at an Executive Committee meeting. The District may have a representative attend these meetings. This subsection does not apply in cases where a member District has, or are considering, initiating litigation on their own behalf.


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SECTION F: OTHER COVERAGE If collectible insurance or any other coverage with any insurer, joint powers insurance authority or other source is available to the covered party covering a loss also covered hereunder (whether on a primary, excess or contingent basis), the coverage hereunder shall be in excess of, and shall not contribute with, such other insurance or coverage, provided that this clause does not apply with respect to insurance purchased specifically to be in excess of the Liability Coverage Memorandum.


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SECTION G: CLAIMS PRESENTATION REQUIREMENTS 1. Notice of Claims (GC §§905, 935, 945.4)

a. No suit for money or damages may be maintained against the District on a cause of action for which this Procedure requires a claim to be presented until a written claim has first been timely presented to the District in conformity with this Procedure.

2. Claims Subject to Claims Presentation Requirements

a. All claims against the District for personal injury, death or damage to personal property are subject to this Procedure.

b. All claims against the District for money or damages which are specifically

exempted from Government Code § 905, and which are not expressly governed by any other statute or regulation, shall be governed by this Procedure. Such claims include the following:

1) Claims under the Revenue and Taxation Code or other statute prescribing

procedures for the refund, rebate, exemption, cancellation, amendment, modification or adjustment of any tax, assessment, fee or charge or any portion thereof, or any penalties, costs or charges related thereto.

2) Claims in connection with which the filing of a notice of lien, statement of

claim, or stop notice is required under any provision of law relating to mechanics’, laborers’ or materialmen’s liens.

3) Claims by public employees for fees, salaries, wages, mileage or other

expenses and allowances. 4) Claims for which the workers’ compensation authorized by Division 4

(commencing with Section 3201) of the Labor Code is the exclusive remedy.

5) Applications or claims for any form of public assistance under the Welfare

and Institutions Code or other provisions of law relating to public assistance programs, and claims for goods, services, provisions or other assistance rendered for or on behalf of any recipient of any form of public assistance.

6) Applications or claims for money or benefits under any public retirement

or pension system.


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7) Claims for principal or interest upon any bonds, notes, warrants, or other evidences of indebtedness.

8) Claims that relate to a special assessment constituting a specific lien

against the property assessed and which are payable from the proceeds of such an assessment, by offset of a claim for damages against it or by delivery of any warrant or bonds representing it.

9) Claims by the State or by a state department or agency or by another local

public entity. 10) Claims arising under any provision of the Unemployment Insurance Code,

including but not limited to claims for money or benefits, or for refunds or credits of employer or worker contributions, penalties, or interest, or for refunds to workers of deductions from wages in excess of the amount prescribed.

11) Claims for the recovery of penalties or forfeitures made pursuant to

Article 1 (commencing with Section 1720) of Chapter 1 of Part 7 of Division 2 of the Labor Code.

12) Claims governed by the Pedestrian Mall Law of 1960, part I (commencing

with Section 11000) of Division 13 of the Streets and Highways Code.

3. Purpose of Claims Presentations Requirements

a. Provides the District with an opportunity to settle just claims before a lawsuit is brought.

b. Permits the District to conduct an early investigation of the facts on which the

claims is based, enabling the District to defend itself against unjust claims and to correct the conditions or practices which gave rise to the claim.

4. Party Responsible to Allow or Reject Claims

a. The Board of Trustees or its designee shall examine and allow or reject claims required to be filed by this Procedure.


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SECTION H: WRITTEN CLAIM 1. Written Claim: Required Information (Government Code § 910) a. Written claims must contain the following information:

1) The name and address of the claimant; 2) The post office address to which the person presenting the claim desires

notices to be sent; 3) The date, place, and other circumstances of the occurrence or transaction

which gave rise to the claim asserted; 4) A general description of the indebtedness, obligation, injury, damage or

loss incurred so far as it may be known at the time of presentation of the claim;

5) The name or names of the public employee or employees causing the

injury, damage or loss, if known; 6) The amount claimed if it totals less than Ten Thousand Dollars ($10,000)

as of the date of claim presentation; including the estimated amount of any perspective injury, damage or loss and so far as it may be known at the time of the presentation of the amount claimed. If the amount claimed exceeds $10,000, no dollar amount shall be included in the claim. However, it shall indicate whether jurisdiction of the claim would rest in limited civil court or not;

7) The signature of the claimant or some person on his or her behalf.

2. Claim Insufficiency (Government Code §§ 910.8 and 911)

a. If the written claim does not substantially comply with the contents requirements of Section II.A, or with the requirements of the District form provided under Section II.B., the claim is insufficient.

b. An insufficient claim should not be rejected, but should be acknowledged with a

written notice of insufficiency. c. Within 20 days after the claim is presented, the Board or its designee shall give

written notice of the claim’s insufficiency stating with particularity the claim’s defects or omissions.

d. The Districts “Notice of Insufficiency” is provided in Exhibit L3.


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e. Written notice of insufficiency shall be given in one of the following ways:

1) Personally delivering the notice to the person presenting the claim; 2) Mailing the notice to the address, if any, stated in the claim or on the

application.

f. When mailing the written notice of insufficiency, the District employee mailing the notice shall executive a “Proof of Service by Mail” provided in Exhibit L10.

g. No notice will be given when the claim fails to state either a street address or post

office address. h. The Board shall not take action on the claim for a period of 15 days after the

written notice of insufficiency is given.

Even if the claim is later rejected, the insufficiency objection can establish a defense. Failure to give timely notice of insufficiency may cause the court to hold that the District is prevented from relying on the failure to properly present the claim, regardless of how insufficient it was.

Many times the claimant will not try to file again, as he may have no way of overcoming the insufficiencies. However, the claimant may file an amended claim.

Claims presented to the wrong entity should also be returned without action. (Exhibit L5) for “Notice of Return Without Action – Incorrect Filing” form.)


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SECTION I: TIMELINESS 1. Claims Which Must be Presented Within Six Months (Government Code § 911.2)

Claims should always be date stamped upon receipt; the envelope also date-stamped and retained. a. Tort claims relating to one of the following must be presented not later than six

(6) months after accrual of the cause of action:

1) Death; 2) Personal injury; 3) Injury to personal property; 4) Injury to growing crops.

Determination whether a claim is timely filed can sometimes be problematic, and if there are any questions, the Executive Director, TPA Adjustor and/or Legal Counsel should be consulted.

2. Claims Which Must be Presented Within One Year (Government Code § 911.2)

a. A claim relating to any other cause of action must be presented within one (1) year of the accrual of the cause of action.

b. Generally these are non-tort claims such as: 1) Breach of contract;

2) Back wages are not generally covered by the VCSSFA. Compliance with the time limit for filing claims is mandatory. There are however, exceptions to the strictness of the requirements, for example, when the injured party is a minor.


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SECTION J: REJECTION / ALLOWANCE OF SUFFICIENT AND TIMELY FILED CLAIMS

1. Board Action Within Forty-Five Days (Government Code § 912.4)

a. The Board shall act on a sufficient and timely submitted claim within forty-five (45) days after the claim has been presented.

1) If the claim was mailed, the Board must act within forty-five (45) days of

the mailing—not receipt—of the claim. 2) If the claim was personally delivered, the Board must act within forty-five

(45) days from the date of delivery. 3) If the Board fails to act within the forty-five (45) day period, the claim is

deemed rejected by operation of law on the forty-fifth (45) day from receipt.

2. Board Action Within Forty-Five Days on Amended Claim (Government Code §

912.4(a))

a. If a claim is amended, the Board shall act on the amended claim within forty-five (45) days after the amended claim is presented.

3. Extension of Time by Agreement

a. The claimant and the Board, by written agreement, may extend the time period within which the Board is required to act on the claim.

b. The extension of time must be given:

1) Before the expiration of the forty-five (45) day period; or 2) After the expiration of the forty-five (45) day period if an action based on

the claim has not been commenced and is not yet barred by the period of limitations provided in Section IV.

c. Any claim which is not acted upon within the extended time period shall be

deemed to have been rejected by the Board or its designee on the last day of the extended time period.

4. Actions the Board May Take (Government Code § 912.6)

a. The Board may act on the claim in one of the following ways:


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1) Reject the claim if the Board finds the claim is not a proper charge against the District;

2) Allow the claim if the Board finds the claim is a proper charge against the

District and is for an amount justly due; 3) Either reject the claim, or allow it in the amount justly due and reject it as

to the balance if the Board finds the claim is a proper charge against the District but is for an amount greater than is justly due;

4) Reject the claim or compromise it if legal liability of the district or the

amount justly due is disputed.

5. Rejection of Timely, Proper and Sufficient Claims

a. A claim with proper and sufficient contents, as provided in Section II. A, and presented in a timely fashion, as provided in Section IV, shall be rejected on its merits. Insufficient or untimely claims will be processed under other sections of this Procedure.

6. Written Rejection (Government Code 913)

a. The claimant has six (6) months in which to file suit on a claim which has been rejected in writing within forty-five (45) days of presentation.

1) The written letter of claim rejection must be substantially in the form

found at Government Code § 913 as provided in Exhibit L6. 2) The written letter of claim rejection must be given in one of the following

ways (Government Code § 915.4):

a) Personally delivering the notice to the person presenting the claim; b) Mailing the notice to the address, if any, stated in the claim or on

the application.

3) When mailing written notice of rejection of claim, the District employee or TPA examiner mailing the notice shall executive a “Proof of Service by Mail” provided in Exhibit L10.

7. Rejection by Operation of Law (Government Code § 912.4)

a. A claim that is not rejected in writing within forty-five (45) days of presentation is deemed rejected by operation of law on the forty-fifth (45th) day following presentation of the claim.


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b. If the Board fails to act on a claim, the claim will be deemed rejected by operation of law on the forty-fifth (45th) day following the date it was mailed or personally delivered to the District. This occurs regardless of whether the claim was filed within six (6) months, filed late, insufficient, or amended.

c. Written “Notice of Rejection of Claim” shall be provided to the claimant for

claims deemed rejected by operation of law as provided in Exhibit L6. d. The written notice of rejection of claim shall be given in one of the following

ways (Government Code §915.4):


application.

e. When mailing written notice of rejection of claim, the District employee or TPA examiner mailing the notice shall execute a “Proof of Service by Mail” provided in Exhibit L10.


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SECTION K: LATE CLAIMS 1. Claims Presented After Six Months of Accrual Date (Government Code §§ 911.4,

911.6 and 911.8)

a. Any claim which is filed late, and which is not accompanied by an Application to Present a Late Claim shall be returned without Board action because it is late and should not be considered on its merits.

b. The District shall provide claimant with written notice of the return of the late

claim filed within forty-five (45) days after the late claim is presented. (Government Code § 911.3). NOTE: The claim must be returned with the notice after making a copy for your files.

c. The written “Notice of Return Without Action – Late Claim” shall be provided to

claimant as set forth in Exhibit L7. d. Written notice of return of late claim shall be given in one of the following ways

(Government Code § 915.4):

1) Personally delivering the notice to the person presenting the claim; 2) Mailing the notice to the address, if any stated in the claim or on the

application.

e. When mailing written notice of return of late claim, the District employee or TPA examiner mailing the notice shall execute a “Proof of Service by Mail” provided in Exhibit L10. NOTE: That no notice be given and no waiver results when the claim as presented fails to state either (1) an address to which the person presenting the claim desires notice to be sent or (2) an address of the claimant.

2. Application to Present a Late Claim (Government Code § 911.4)

a. Should the claimant fail to present a claim within the time provided in Section IV.A. (i.e.; no later than six (6) months after the accrual of the cause of action), the claimant must present an Application to Present a Late Claim.

b. The Application to Present a Late Claim must:

1) Be Presented to the District within one (1) year after the accrual of the cause of action;

2) Set forth the reasons for the delay;


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3) Have written claim attached. In computing the one-year period within which the application must be filed, the time during which the person who sustained the alleged injury, damage or loss is a minor shall be counted, but the time that he is mentally incapacitated and does not have a guardian or conservator shall not be counted.

c. Partially Late/Partially Timely Claims

1) A claim that contains several causes of action will be reviewed to determine which causes of action are timely or untimely filed.

2) Written notice of rejection or allowance, pursuant to Section V, will be

provided to claimant for those causes of action within the claim which are sufficient and timely presented.

3) Written notice of late filing, pursuant to Section VI, will be provided to

claimant for those causes of action within the claim which are not timely presented.

3. Acceptance of Application to Present a Late Claim (Government Code § 911.6)

a. The Board shall grant the Application to Present a Late Claim in the following instances:

1) The failure to timely present the claim was due to mistake, inadvertence,

surprise or excusable neglect, and the public entity District is not prejudiced its defense of the claim by the claimant’s failure to timely present the claim; or

2) The person who sustained the alleged injury, damage or loss was a minor

during the entire 6-month or one-year, as applicable, limitation period all the time specified in Section IV for the presentation of the claim; or

3) The person who sustained the alleged injury, damage or loss was

physically or mentally incapacitated during the entire 6-month or one-year limitation period and by reason of this disability failed to present a claim during the time period all the time specified in Section IV for the presentation of the claim; or

4) The person who sustained the alleged injury, damage or loss died before

the expiration of the time specified in Section IV for the presentation of the claim.

b. The Board will take action to grant or deny the Application to Present a Late

Claim within forty-five (45) days after it has been presented.


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1) The claimant and the Board may extend the period within which the Board

will act on the application by written agreement made before the end of the forty-five (45) day period.

2) If the Board does not act within the extended period of time, the

application shall be deemed denied on the last day specified in the Memorandum.

If the Board denies the application, the claimant may within six months of the denial or the date on which the application was deemed to be denied, file a petition in superior court for relief from the claim procedure. If the court grants relief, the claimant must file a lawsuit within 30 days of the court order for relief. The burden is on the claimant to show cause in court as to why the claim was late and why the delay should be excused. Failure to have knowledge of the law in and of itself is not excusable neglect.

c. Written notice of the Board’s action to grant the “Notice of Action Granting Application to Present a Late Claim” shall be provided to the claimant as provided in Exhibit L9.

d. The written notice of Board action to grant the Application to Present a Late

Claim shall be given in one of the following ways:


application.

e. When mailing written notice of Board action of an Application to Present a Late Claim, the District employee mailing the notice shall executive a “Proof of Service by Mail” provided in Exhibit L10.

4. Denial of Application to Present a Late Claim Presented Within One Year of the

Accrual of the Cause of Action (Government Code §§ 911.8, 946.6)

a. The district will deny the Application to Present a Late Claim if it is not excused pursuant to Section VI.C.1.

b. Written notice of the Board’s action denying the “Application to Present a Late

Claim” shall be provided to claimant as provided in Exhibit L8. c. Written notice of denial of “Application to Present a Late Claim” shall be given in

one of the following ways:


Revised 07/01/14 20

1) Personally delivering the notice to the person presenting the claim;

2) Mailing the notice or to the address, if any, stated in the claim or on the application.

d. When mailing written notice, the district employee mailing the notice shall

execute a “Proof of Service by Mail” provided in Exhibit L10.

5. Denial of Application to Present a Late Claim Presented After One Year From the Accrual of the Cause of Action (Government Code § 911.4(b))

a. Any Application to Present a Late Claim filed, or presented, a year or more from

the date of accrual of the cause of action shall be denied in writing as provided in Exhibit L11 (“Notice of Denial of Application to Present a Late Claim Filed Over One Year After Accrual of the Cause of Action”).

b. The Written notice of denial of an Application to Present a Late Claim Filed After

One Year shall be given in one of the following ways:

1) Personally delivering the notice to the person presenting the claim; 2) Mailing the notice or to the address, if any, stated in the claim or on the

application.

c. When mailing written notice of denial of an Application to Present a Late Claim After One Year, the District employee mailing the notice shall executive a “Proof of Service by Mail” provided in Exhibit L10.

CONSEQUENCES IF THE BOARD FAILS TO ACT ON CLAIMS: Any claim presented to a public entity is rejected as presented, by operation of law, on the 45th day following the date it was actually received by the public entity. This is true regardless of whether the claim was filed within six months, late, insufficient or amended. Failure by the Board to respond properly to the claim document may limit the Board’s future defenses to the claim. Giving written notice of action or inaction is important. A claimant has only 6 months to file a lawsuit after receipt of written notice, and two (2) years or longer if there is no written notice. As mentioned earlier, the adjustor faced with a clear liability case or a reasonable or cooperative claimant may deem it advisable to extend the suit-filing period. In those cases, the District shall allow rejection by operation of law. The Government Code is very complex and subject to legislative and judicial changes and interpretations. The above is not intended to cover all claim conditions; although it does cover many of the situations encountered.


Revised 07/01/14 21

SECTION L: AMENDMENT OF CLAIMS 1. Time to Amend Claim (Government Code §910.6)

a. A claim may be amended at any time before the expiration of the period designated in Section IV or before final action on the claim is taken by the Board, whichever is later.

2. Amended Claim Must Relate to Original Claim

a. The amended claim must relate to the same transaction or occurrence, which gave rise to the original claim.

b. The amendment shall be considered a part of the original claim for all purposes.


Revised 07/01/14 22

SECTION M: INSURANCE / JOINT POWERS AUTHORITY The District will comply with applicable requirements of its agreements with liability carriers regarding notice of claims and other information to be provided to the carriers and regarding tender of defense.

PLEASE NOTE THAT IT IS THE MEMBER DISTRICT’S OR THE TPA EXAMINER’S RESPONSIBILITY TO SEND THE DENIAL, REJECTION, LATE AND INSUFFICIENCY NOTICES IN RESPONSE TO WRITTEN CLAIMS AGAINST THEM.

NOTE: Please ensure that any correspondence concerning a claim goes into a separate file as this material is considered to be confidential and could pertain to pending litigation (i.e., do NOT file it in a student’s cumulative file or an employee’s personnel file).

Exhibit L1

23

Ventura County Schools Self-Funding Authority Report of Personal Accident

CONFIDENTIAL – ATTORNEY – CLIENT PRIVILEGE TO BE COMPLETED IMMEDIATELY

THE SCHOOL EMPLOYEE WHO EITHER WITNESSES THE INJURY OR IS SUPERVISING AT THE TIME OF INJURY SHOULD COMPLETE THIS FORM, IF POSSIBLE. THE REPORT SHOULD BE SUBMITTED IMMEDIATELY TO THE APPROPRIATE SCHOOL DISTRICT OFFICE. SHOULD OTHER PERTINENT FACTS DEVELOP, NOTIFY THE SCHOOL DISTRICT OFFICE BY MEANS OF A SUPPLEMENTAL REPORT.

STUDENT PARENT VISITOR

VENDOR OTHER

SCHOOL DISTRICT SCHOOL

SCHOOL ADDRESS TELEPHONE NO.

INJURED PARTY'S NAME SEX AGE GRADE

HOME ADDRESS DAY TELEPHONE HOME TELEPHONE

WHERE DID ACCIDENT OCCUR? DATE TIME

HOW DID ACCIDENT OCCUR?

STATEMENT OF INJURED PARTY

EMPLOYEE IN CHARGE OF INJURED STUDENT AT TIME OF ACCIDENT: WAS EMPLOYEE PRESENT AT THE TIME OF ACCIDENT?

YES NO WAS ANY SCHOOL RULE VIOLATED? YES NO

IF SO, EXPLAIN

NAME

WITNESSES PRESENT AT TIME OF ACCIDENT ADDRESS

TELEPHONE

NATURE OF INJURY DISABLED? YES NO

FIRST AID APPLIED? YES NO

BY WHOM? HAVE PARENTS CONTACTED SCHOOL? YES NO

DISPOSITION OF INJURED PARTY (RETURN TO CLASS, HOME, DOCTOR, HOSPITAL)

NAME OF PERSON NOTIFIED

LIST NAME OF STUDENT'S SCHOOL ACCIDENT INSURANCE COVERAGE BY WHOM NOTIFIED? DATE TIME

COMMENTS

REPORT SUBMITTED BY POSITION TELEPHONE DATE

SFA 4010, Rev.3/18/2014 Send to: York Insurance Services Group District: DO NOT keep a copy of the completed form

Exhibit L2

24

RE: Claimant: Date of Incident: Date Claim Made: Our File No.: To Whom It May Concern: We have reviewed the above claim that you have reported and request you take the action indicated below: ______ CLAIM REJECTION: Reject claim in accordance with Government Code,

Section 913. (Exhibit L6) ______ LATE CLAIM: Do NOT reject claim, but RETURN it for failure to file within time

limit prescribed in Government Code, Section 911.2 Transmittal NOT to contain ‘WARNING’ required by Section 913, but should advise that the recourse is to file “Application for Leave to File Late Claim” as provided in Government Code, Section 911.4. This must be returned within 45 days of the date claim mailed or delivered. (Exhibit L7)

______ INSUFFICIENT CLAIM: Send notice of insufficiency for failure to comply with

Government Code, Section 910 and/or 910.2 and/or 910.4 and cite the following specific insufficiencies: (Exhibit L3)

_______________________________________________________________________________________________________________________________________________________________________________________________________________

This must be sent within 20 days of your receipt of claim. ______ AMENDED CLAIM: Reject claim as set forth in first paragraph above, CLAIM

REJECTION. (Exhibit L6)

______ NOTICE OF DENIAL OF APPLICATION TO PRESENT A LATE CLAIM: Reject the Application under Government Code, Section 911.8. (Exhibit L8)

______ NOTICE OF ACTION GRANTING APPLICATION TO PRESENT A LATE CLAIM (Exhibit L9)

______ OPERATION OF LAW: Defer any written response pending our further advice.

______ PROOF OF SERVICE BY MAIL (Exhibit L10) Please provide us with a copy of any response requested above. If you have any questions, please contact the undersigned. Very truly yours,

Exhibit L3

25

NOTE: THIS LETTER SHOULD BE TYPED ON DISTRICT LETTERHEAD AND USED TO NOTIFY POTENTIAL CLAIMANTS OF INSUFFICIENCIES IN CLAIMS FILED WITHIN 20 DAYS AFTER THE CLAIM IS PRESENTED.

NOTICE OF INSUFFICIENCY (Within 20 Days After Claim Presented)

Date: ___________________________________ Re: ___________________________________ File: ___________________________________ Claimant: _________________________________ This is to acknowledge receipt of your claim dated _______________________, 20____, and to

advise you that pursuant to California Government Code Section 910, your claim, as presented, is

insufficient and fails to comply substantially with the requirement as set forth therein. Specifically,

it fails to:

____________________________________________________________________ (indicate insufficiency)

____________________________________________________________________

or

The_________________________________does not own, maintain, control, administer nor (name of public entity) staff the specific function or loss in question, and your claim should be directed to the proper

agency. You may correct the insufficiency by filing an amended claim supplying the missing

information listed above. You have 15 days after the date of this letter or six months from the date

of the alleged accident, whichever is later, in which to file this amended claim. If you fail to

provide the missing information, your claim MAY be denied and you may also lose the right to

initiate a lawsuit.

By: __________________________________

Certified Mail

Return Receipt Requested

Revised 7/1/02

(District Letterhead/Logo Here) Exhibit L4

SFA 4020, Rev. 3/18/2014 26

VERIFIED CLAIM FORM Damages to Person or Property

Instructions 1. Claims to death, injury to person or property must be filed not later than six (6) months

after the occurrence (Government Code § 911.2) 2. Claim for damages to real property must be filed not later than one (1) year after the

occurrence (Government Code § 911.2) 3. Read entire claim form before filing 4. This claim form must be signed on page 2 at the bottom 5. Attach separate sheets, if necessary, to give full details. PLEASE SIGN EACH SHEET

Date Stamp

To: (School District) (School Name)

Name of Claimant Date of Birth

Home Address of Claimant City, State, Zip Social Security Number

Business Address of Claimant City, State, Zip Preferred Telephone

Give address and telephone number to which you desire notices to be sent

Date and time of Injury, Damages, or Loss Location (exact location)

Nature of Injury, Damages, or Loss:

If no injuries, so state:

The circumstances giving rise to this claim are as follows:

Why do you claim the district or school is responsible?

Verified Claim Form Page 2

The personal information contained in this form will be kept confidential

27

The names of the public employees causing the claimant’s injuries are:

If the amount of the claim is less than $10,000, please itemize expenses related to the claim:

Total Amount claimed as of date of presentation of this claim (less than $10,000): $

If the amount of the claim exceeds $10,000, indicate the following: Limited Jurisdiction (less than $25,000),

Unlimited Jurisdiction

Was injury or damage investigated by police? Yes No Police Department and Report Number

Were paramedics or ambulance called? Yes No Fire Department or Ambulance Company Witnesses:

Name Address Telephone



Hospitals, Doctors, Medical Providers:

Hospital Address Telephone

Doctor or other Provider Address Telephone

Doctor or other Provider Address Telephone

The undersigned states that he or she is the person making the above stated claim, or is a person representing said claim and acting on behalf of the claimant above named, and declares under penalty of perjury that the foregoing is true and correct insofar as is known as of this date.

Date City, State

Signature of Claimant or Authorized Representative Relationship to Claimant

Exhibit L5

28

NOTICE OF RETURN WITHOUT ACTION –

INCORRECT FILING

Re: ___________________________________________________

File: ___________________________________________________

Claimant: ________________________________________________

This is to acknowledge receipt of your claim dated _______________________, 20_____, and to

advise you that the ___________________________________does not own, maintain, control,

administer nor staff the specific function or loss in question, and your claim should be directed to

the proper agency.

Your claim is returned herewith.

By:_______________________________________

Certified Mail

Return Receipt Requested

Revised 7/1/02

Exhibit L6

29

NOTE: THIS LETTER SHOULD BE TYPED ON DISTRICT LETTERHEAD AND USED TO NOTIFY POTENTIAL CLAIMANTS THAT THEIR CLAIM HAS BEEN REJECTED ON ITS MERITS, NOT BECAUSE THE CLAIM IS LATE OR INSUFFICIENT AS TO THE CONTENT. THIS NOTICE MUST BE MAILED WITHIN 45 DAYS OF PRESENTATION OF THE CLAIM (Govt. Code §913)

NOTICE OF REJECTION OF CLAIM (Government Code Sec. 913)

To:________________________________________________ Re:_________________________________________________ NOTICE IS HEREBY GIVEN that the claim that you presented to the __________________________________, on _____________________, 20______________, was (District Name)

(Indicate whether rejected, allowed, allowed in the amount of $_________________, rejected by

operation of law, or other appropriate language) on _______________________, 20______.

W-A-R-N-I-N-G

(This warning applies if the claim is rejected in whole or in part.)

Subject to certain exceptions, you have only six (6) months from the date this Notice was personally

delivered or deposited in the mail, to file a State Court Action on this claim. (See Government code

Sec. 945.6)

You may seek the advice of an attorney of your choice in connection with this matter. If you desire

to consult an attorney, you should do so immediately. Should you file a lawsuit in this matter which

is determined to be in bad faith and without reasonable cause, please be advised that the

(DISTRICT NAME) will attempt to recover all of its defense costs from you as allowed by

California Code of Civil Procedure §128.5 and §1038.

By:___________________________________

Certified Mail Return Receipt Requested Revised 7/1/02

Exhibit L7

30

NOTICE OF RETURN WITHOUT ACTION - LATE CLAIM

(Within 45 Days After Claim Presented) To: ________________________________________________ Re: ________________________________________________ NOTICE IS HEREBY GIVEN that the claim you presented to

the__________________________on_______________________, 20________, is

(District Name) being returned because it was not presented within 6-months after the event or occurrence as

required by law. (See Sections 901 and 911.2 of the Government Code.) Because the claim was

not presented within the time allowed by law, no action was taken on the claim.

Your only recourse at this time is to apply without delay to______________________________________ for leave to present a late claim. (District Name)

(See Sections 911.14 to 912.2 inclusive, and Section 946.6 of the Government Code.) Under

some circumstances, leave to present a late claim will be granted. (See Section 911.6 of the

Government Code.)

You may seek the advice of an attorney of your choice in connection with this matter. If you

desire to consult an attorney, you should do so immediately.

By:_________________________________

Certified Mail

Return Receipt Requested Revised 7/1/02

Exhibit L8

31

NOTE: THIS LETTER SHOULD BE TYPED ON DISTRICT LETTERHEAD AND USED TO REJECT LATE CLAIMS PRESENTED WITHIN ONE YEAR OF ACCRUAL (GOVT. CODE §911.8)

NOTICE OF DENIAL OF APPLICATION

TO PRESENT A LATE CLAIM Date: _______________________________ Name: _______________________________ Address: _______________________________

_______________________________ _______________________________ Re: Notice of Denial of Applicaton to Present A Late Claim to the (District Name) Dear_____________: Your Application to Present a Late Claim was presented to the (District Name) on (date) and was denied on said wate.

W-A-R-N-I-N-G

If you wish to file a court action on this matter, you must first petition the appropriate court for an order relieveing you from the provisions of Government Code Section 945.4 (claims presentation requirement). See Government Code Section 946.6. Such petition must be filed with the court within Six (6) months from the date of your application for leave to present a late claim was denied. You may seek the advice of an attorney of your choice in connection with this matter. If you desire to consult an attorney, you should do so immediately.

Sincerely, _____________________________ Certified Mail


Exhibit L9

32

NOTE: THIS LETTER SHOULD BE TYPED ON DISTRICT LETTERHEAD AND USED TO NOTIFY CLAIMANTS OF ACTION GRANTING AN APPLICATION TO PRESENT A LATE CLAIM WITHIN 45 DAYS AFTER CLAIM PRESENTED (GOVT. CODE §911.8)

NOTICE OF ACTION GRANTING APPLICATION TO PRESENT A LATE CLAIM

Date: ________________________________ Name: ________________________________ Address: ________________________________ ________________________________ ________________________________ Re: Notice of Action Granting an Application to Present a Late Claim to the (DISTRICT

NAME) Dear_____________: The Application to Present a Late claim which you presented to the (DISTRICT NAME) on (DATE) was granted on (DATE). Your claim is now under consideration by the (DISTRICT NAME) and will be acted upon within forty-five (45) days after the date on which your application was granted, as set forth above, subject to any extension of time authorized by law. Sincerely, ____________________________ Certified Mail


Exhibit L10

33

PROOF OF SERVICE BY MAIL

I, ________________________, am employed in (insert County), the county where the

mailing occurred. My business address is (DISTRICT NAME and Address). I am over the age of

eighteen years, and not a party to the within action.

On _________________, I sent by U. S. mail, certified with return receipt requested, the

following document: _____________________________ dated_______________, by placing a

copy of the document in an envelope for the addressee named below and addressed to such

addressee as follows:

Mr./Ms./Mrs. __________________________

__________________________

__________________________

__________________________

I am readily familiar with the school district’s practice of collection and processing

correspondence for mailing with the U. S. Postal Service. Under that practice it would be deposited

with the U. S. Postal Service on that same day with postage thereon fully prepaid in the ordinary

course of business.

I declare under penalty of perjury under the laws of the State of California that the above is

true and correct.

Executed on __________________, at (insert city), California

_________________________________ (Type Name) Revised 7/1/02

Exhibit L11

34

NOTE: THIS LETTER SHOULD BE TYPED ON DISTRICT LETTERHEAD AND USED TO REJECT AN APPLICATION TO PRESENT A LATE CLAIM PRESENTED AFTER ONE YEAR FROM ACCRUAL (GOVT. CODE §911.4)

NOTICE OF DENIAL OF APPLICATION TO PRESENT A LATE CLAIM FILED OVER ONE YEAR AFTER ACCRUAL OF THE

CAUSE OF ACTION

Date: ________________________________ Name: ________________________________ Address: ________________________________ ________________________________ ________________________________ Re: Notice of Denial of Application to Present a Late Claim to the (DISTRICT NAME) Dear_____________: The Application to Present a Late Claim which you presented to the (DISTRICT NAME) on (DATE) has been denied by the Board of Trustees. The Application to Present a Late Claim was not presented within the time required by law. To determine whether you have any further remedy or whether further procedures are open to you, you may wish to consult with an attorney. If you decide to consult with an attorney, you should do so immediately. Sincerely, ____________________________ Certified Mail


Revised 07/01/14

Property Claims Procedures

Revised 07/01/14 36

PROPERTY CLAIMS PROCEDURES

SECTION A: CLAIMS REPORTING INSTRUCTIONS

1. General

The Property Claims procedure applies to property claims (i.e. property owned, leased or under the care and custody of the District). When there is a question about whether a claim is covered by the Property Program, you can either call the TPA or fill out the appropriate form and send it into the TPA for a determination of coverage.

2. It is the responsibility of the District to ensure that a VCSSFA "Report of Property Loss Notice" (see Exhibits P1 and P2) and the applicable section dealing with a specific coverage) is completed and sent in to the TPA.

3. The top copy of the form shall be sent immediately to the TPA, in care of YORK Risk

Services Group, P.O. Box 5980, Oxnard, CA 93031 FAX: (805) 981-1428. Note: If other pertinent information becomes available later, please send this information to the TPA.

4. For any serious property loss, immediately phone the TPA - do not delay reporting! 5. Making School Employees Aware

It is very important that each school employee be aware of the need to promptly and correctly report accidents and losses involving school property. Identification of witnesses is especially important and this information should be forwarded to the District Office, who in turn should send it to the TPA.

School employees should discuss the facts of accidents and losses only with authorized representatives of the School District, law enforcement authorities and the TPA Claims Examiners.

VCSSFA Property Claims Procedures Fiscal Year 2014-2015

Revised 07/01/14 37

SECTION B: CLAIMS HANDLING PROCEDURES

NOTE: Certain terms and language used in the following sections have been simplified. The VCSSFA Memorandum of Coverage and applicable insurance policies secured by the VCSSFA on behalf of its members will be the final factors in determining issues of coverage. Copies of these documents are provided to each VCSSFA Board Member on an annual basis. Districts also have deductibles under each program which must be met and these are also outlined in the Memorandum of Coverage. 1. Fire Property Losses

a. Brief description of coverage: This coverage applies to real property (i.e. buildings, structures, etc.) and contents of the District and, in some instances, to personal property of others for which the District is liable.

b. Examples of losses covered: damage to buildings and contents due to fire, smoke,

vandalism, or malicious mischief, wind storm, vandalism damage to glass, etc. c. Examples of losses not covered: damage due to earth movement (i.e.

earthquakes, flood, etc.) d. Claims Handling Procedures

1) Upon knowledge of a loss, the District must immediately fill out a "Property Loss Notice" form (Exhibit P1) and send it to the TPA. In cases of severe or large loss, the TPA should be called immediately, day or night, weekends or holidays.

2) The TPA will prepare and send an "Acknowledgment of Loss" form

(Exhibit P3) to the District. 3) In instances of extremely large losses, the following should be done to

expedite the claims payment process:

a) Once the TPA has been notified of the loss, the District should follow applicable codes concerning the bid process. Once the bid process has been completed, the District should notify the TPA of this fact.

b) The TPA will, during the course of the claims process, make

payments on behalf of the District and the VCSSFA, directly to the various contractors, in both "emergency" and "regular" claim situations.

c) The TPA will then apply for reimbursement on behalf of the

VCSSFA from the Excess Insurance Carrier.


Revised 07/01/14 38

4) The TPA will conduct any applicable investigation, set up reserves, and keep the District informed on the status of the claim.

5) Claims under a District's SIR (Self-Insured Retention) will not be paid by

the VCSSFA. 6) Claims over a District's SIR will be paid on behalf of the VCSSFA by the

TPA.

2. Difference In Conditions (DIC) Claims

a. Brief description of coverage: This coverage applies to losses of personal property of the District (i.e. desks, chairs, equipment, etc.) used in the operation of the District.

b. Examples of losses covered: loss due to theft. c. Examples of items not covered: Currency, money, trees, automobiles, glass, loss

or damage caused or resulting from vandalism and malicious mischief, etc. d. Claims Handling Procedures

1) Upon knowledge of a loss, the District should immediately fill out a "Property Loss Notice" form (Exhibit P1) and send it to the TPA. The district must also file a police report.

NOTE: No claim under $100 shall be submitted by a District to the TPA and no claim will be processed by the TPA if they have received it 30 days or more after the District's date of knowledge of the loss.

2) The TPA will prepare and send an "Acknowledgment of Loss" form (Exhibit P3) to the District.

3) The TPA will conduct any applicable investigation, set up reserves, and

keep the District informed of the status of the claim. 4) Claims under the District's SIR will not be paid by the VCSSFA. 5) Claims over a District's SIR will be paid on behalf of the VCSSFA by the

TPA. The TPA will then obtain any applicable reimbursement from the excess insurance carrier.

3. Boiler and Machinery Claims

a. Brief description of coverage: This coverage applies to boilers, refrigerating and air-conditioning systems, compressors, etc.


Revised 07/01/14 39

b. Examples of losses covered: losses due to an accident (i.e. a sudden and accidental breakdown) of the object (machinery) or part of the object.

c. Examples of losses not covered: losses due to deterioration, corrosion, wear and

tear, etc. d. Claims Handling Procedures:

1) Upon knowledge of a loss, the District must immediately fill out a "Property Loss Notice" form (Exhibit P1) and send it to the TPA. In case of a severe or large loss, the TPA should be called immediately to include evenings, weekends and holidays.

2) The TPA will prepare and send an "Acknowledgment of Loss" form

(Exhibit P3) to the District. 3) The TPA will forward this type of claim to the Boiler and Machinery

Insurance Company for processing and payment of the loss. 4) The TPA will keep the District informed of the status of the claim. 5) Claims under a District's deductible will not be paid. 6) Claims over a District's deductible will be paid directly to the District by

the Boiler and Machinery Insurance Company.

4. Automobile Physical Damage Claims

a. Brief description of coverage: This coverage will apply to District-owned cars, buses, trucks, etc. and to vehicles hired by the District.

b. Examples of losses covered: losses due to theft, accidents (to include rental cars

hired by District personnel while on District business), damage due to vandalism, etc.

c. Examples of losses not covered: damage to an employee’s auto. d. Claims Handling Procedures

1) Upon knowledge of a loss, the District should immediately fill out a "Property Loss Notice" form (Exhibit P1) and send it to the TPA. In case of a large loss, the TPA should be called immediately to include evenings, weekends and holidays.

2) The TPA will prepare and send an "Acknowledgment of Loss" (Exhibit

P3) to the District.


Revised 07/01/14 40

3) The TPA will conduct any applicable investigation, set-up reserves, and keep the District informed of the status of the claim.

4) Claims under a District's SIR will not be paid by the VCSSFA. 5) Claims over a District's SIR will be paid on behalf of the VCSSFA by the

TPA.


Revised 07/01/14 41

SECTION C: DETERMINATION ON COVERAGE ISSUES AND APPEAL PROCEDURES

The VCSSFA is not an insurer and does not insure its members. The Authority is the alter ego of its members who have joined by agreement to pool their losses by forming self-insurance pools. The VCSSFA is governed by the Board of Directors, which may review all acts and shall have the power to modify and/or override any decision or action upon a majority vote of the entire Board of Directors. Any member protected by the Program of the VCSSFA may have any decision denying protection of any claim ultimately reviewed by the Board of Directors. The VCSSFA TPA shall act on behalf of the VCSSFA and its members. The VCSSFA shall have the sole and exclusive right to choose and select investigators and defense counsel, to defend members, and to settle and compromise claims, lawsuits and judgments, in the manner it deems in the best interests of the members of the VCSSFA.

The VCSSFA shall have no right, duty or obligation to pay for or defend claims which are not within the coverages provided and defined in the Excess Insurance policies and/or as outlined in the Memorandum of Coverage for the covered period. In the event the VCSSFA determines that no part of a claim, demand or lawsuit forwarded to it by a member is within the provisions of the General Property Program, the VCSSFA shall notify the member of that determination. Thereafter, the member shall have the sole responsibility for the defense, managing, handling, and disposing of the said claim, demand or lawsuit, including any judgment arising therefrom, without any right of reimbursement, assistance or protection from the VCSSFA.

In summary, the VCSSFA shall assume responsibility only for expenses, charges, or payments directly authorized by the VCSSFA through the TPA.


Revised 07/01/14 42

SECTION D: OTHER COVERAGE If collectible insurance or any other coverage with any insurer, joint powers insurance authority or other source is available to the covered party covering a loss also covered hereunder (whether on a primary, excess or contingent basis), the coverage shall be in excess of, and shall not contribute with, such other insurance or coverage, provided that this clause does not apply with respect to insurance purchased specifically to be in excess of the Memorandum of Coverage.


Revised 07/01/14 43

SECTION E: FORMS Forms included as Exhibit P1 and P2 can be obtained on the VCSSFA website at vcssfa.org.

Exhibit PI

P R O P E R T Y L O S S NOTICE DATE (MM/DDATYY)

A G E N C Y INSURED LOCATION C O D E DATE OF L O S S AND TIME AM

PM

A G E N C Y

P R O P E R T Y / HOME POLICY

A G E N C Y

C A R R I E R NAIC C O D E

CONTACT NAME:

POLICY NUMBER

PHONE ( A ; C . N O . Extl:

POLICY NUMBER

F A X ( A / C . N O ) ;

FLOOD POLICY

E-MAIL A D D R E S S !


C O D E : S U B C O D E :


A G E N C Y CUSTOMER ID: POLICY NUMBER POLICY NUMBER

WIND POLICY


POLICY NUMBER

INSURED NAME O F INSURED (First, Middle, Last) INSURED'S MAILING A D D R E S S

DATE OF BIRTH FEIN (If applicable) MARITAL STATUS / CIVIL UNION (If applicable)

INSURED'S MAILING A D D R E S S

P H O N E " * • • BUS • C E L L PHONE • HOME • B U S • C E L L PRIMARY E-MAIL A D D R E S S : P H O N E " * • • BUS • C E L L PHONE • HOME • B U S • C E L L

S E C O N D A R Y E-MAIL A D D R E S S :

NAME O F S P O U S E (First, Middle, Last) (if applicable) S P O U S E ' S MAILING A D D R E S S (If applicable)

DATE OF BIRTH FEIN (if applicable) MARITAL STATUS / CIVIL UNION (if applicable)

S P O U S E ' S MAILING A D D R E S S (If applicable)

P H O N E * • • BUS • C E L L P H O N E * ' ^ ' ' ^ • HOME • B U S • C E L L PRIMARY E-MAIL A D D R E S S : P H O N E * • • BUS • C E L L P H O N E * ' ^ ' ' ^ • HOME • B U S • C E L L


CONTACT CONTACT INSURED

N A M E O F CONTACT (First, Middle, Last) CONTACT'S MAILING A D D R E S S

P H O N E ' J • HOME • BUS • C E L L PHONE S * " ^ • HOME • B U S • C E L L

CONTACT'S MAILING A D D R E S S

WHEN TO CONTACT PRIMARY E-MAIL A D D R E S S :

WHEN TO CONTACT


L O S S LOCATION OF L O S S

S T R E E T :

P O L I C E OR F I R E DEPARTMENT CONTACTED

CITY, STATE, ZIP: R E P O R T NUMBER

COUNTRY:

R E P O R T NUMBER

D E S C R I B E LOCATION OF L O S S IF NOT AT SPECIF IC S T R E E T A D D R E S S :

FIRE

THEFT

LIGHTNING

HAIL

FLOOD 1 1 FIRE

THEFT

LIGHTNING

HAIL W/IND

KIND OF L O S S

P R O B A B L E AMOUNT ENTIRE L O S S

DESCRIPTION O F L O S S & DAMAGE (ACORD 101, Additional Remarks Schedule, may be attached if more space Is required)

R E P O R T E D B Y R E P O R T E D TO

A C O R D 1 (2013/01) Page 1 of 3 © 1988-2013 A C O R D CORPORATION. All rights reserved.

The A C O R D name and logo are registered marks of A C O R D

44

AGENCY CUSTOMER ID:

R E M A R K S (ACORD 101, Additional Remarks Schedule, may be attached If more space is required)

APPLICABLE IN ALABAMA

Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or who knowingly presents false information in an application for insurance is guilty of a crime and may be subject to restitution fines or confinement in prison, or any combination thereof.

APPLICABLE IN ALASKA

A person who knowingly and with intent to injure, defraud, or deceive an insurance company files a claim containing false, incomplete, or misleading information may be prosecuted under state law.

APPLICABLE IN ARIZONA

For your protection, Arizona law requires the following statement to appear on this form. Any person who knowingly presents a false or fraudulent claim for payment of a loss is subject to criminal and civil penalties.

APPLICABLE IN ARKANSAS, DELAWARE, KENTUCKY, LOUISIANA, MAINE, MICHIGAN, NEW J E R S E Y , NEW MEXICO, NEW YORK, NORTH DAKOTA, PENNSYLVANIA, RHODE ISLAND, SOUTH DAKOTA,

TENNESSEE, TEXAS, VIRGINIA, AND WEST VIRGINIA

Any person who knowingly and with intent to defraud any insurance company or another person, files a statement of claim containing any materially false information, or conceals for the purpose of misleading, information concerning any fact, material thereto, commits a fraudulent insurance act, which is a crime, subject to cnminal prosecution and [NY: substantial] civil penalties. In LA, ME, TN, and VA, insurance benefits may also be denied.

APPLICABLE IN CALIFORNIA

For your protection, California law requires the following to appear on this form: Any person who knowingly presents a false or fraudulent claim for payment of a loss is guilty of a crime and may be subject to fines and confinement in state prison.

APPLICABLE IN COLORADO

it is unlawful to knowingly provide false, incomplete, or misleading facts or information to an insurance company for the purpose of defrauding or attempting to defraud the company. Penalties may include imprisonment, fines, denial of insurance, and civil damages. Any insurance company or agent of an insurance company who knowingly provides false, incomplete, or misleading facts or information to a policy holder or claimant for the purpose of defrauding or attempting to defraud the policy holder or claimant with regard to a settlement or award payable from insurance proceeds shall be reported to the Colorado Division of Insurance within the Department of Regulatory Agencies.

A C O R D 1 (2013/01) Page 2 of 3

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AGENCY CUSTOMER ID:

APPLICABLE IN THE DISTRICT OF COLUMBIA

Warning: It is a crime to provide false or misleading information to an insurer for the purpose of defrauding the insurer or any other person. Penalties include imprisonment and/or fines. In addition, an insurer may deny insurance benefits, if false information materially related to a claim w as provided by the applicant.

APPLICABLE IN FLORIDA

Pursuant to S. 817.234, Florida Statutes, any person who, with the intent to injure, defraud, or deceive any insurer or insured, prepares, presents, or causes to be presented a proof of loss or estimate of cost or repair of damaged property in support of a claim under an insurance policy knowing that the proof of loss or estimate of claim or repairs contains any false, incomplete, or misleading information concerning any fact or thing material to the claim commits a felony ofthe third degree, punishable as provided in S. 775.082, S. 775.083, or S. 775.084, Florida Statutes.

APPLICABLE IN HAWAII

For your protection, Hawaii law requires you to be informed that presenting a fraudulent claim for payment of a loss or benefit is a crime punishable by fines or imprisonment, or both.

APPLICABLE IN IDAHO

Any person who knowingly and with the intent to injure, defraud, or deceive any insurance company files a statement of claim containing any false, incomplete or misleading information is guilty of a felony.

APPLICABLE IN INDIANA

A person who knowingly and with intent to defraud an insurer files a statement of claim containing any false, incomplete, or misleading information commits a felony.

APPLICABLE IN KANSAS

Any person who, knowingly and with intent to defraud, presents, causes to be presented or prepares with knowledge or belief that it will be presented to or by an insurer, purported insurer, broker or any agent thereof, any written statement as part of, or in support of, an application for the issuance of, or the rating of an insurance policy for personal or commercial insurance, or a claim for payment or other benefit pursuant to an insurance policy for commercial or personal insurance which such person knows to contain materially false information concerning any fact material thereto; or conceals, for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act.

APPLICABLE IN MARYLAND

Any person who knowingly or willfully presents a false or fraudulent claim for payment of a loss or benefit or who knowingly or willfully presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison.

APPLICABLE IN MINNESOTA A person who files a claim with intent to defraud or helps commit a fraud against an insurer is guilty of a crime.

APPLICABLE IN NEVADA

Pursuant to NRS 686A.291, any person who knowingly and willfully files a statement of claim that contains any false, incomplete or misleading information concerning a material fact is guilty of a felony.

APPLICABLE IN NEW HAMPSHIRE

Any person who, with purpose to injure, defraud or deceive any insurance company, files a statement of claim containing any false, incomplete or misleading information is subject to prosecution and punishment for insurance fraud, as provided in RSA 638:20.

APPLICABLE IN OHIO

Any person who, with intent to defraud or knowing that he/she is facilitating a fraud against an insurer, submits an application or files a claim containing a false or deceptive statement is guilty of insurance fraud.

APPLICABLE IN OKLAHOMA

WARNING: Any person who knowingly and with intent to injure, defraud or deceive any insurer, makes any claim for the proceeds of an insurance policy containing any false, incomplete or misleading information is guilty of a felony.

APPLICABLE IN WASHINGTON

It is a crime to knowingly provide false, incomplete, or misleading information to an insurance company for the purpose of defrauding the company. Penalties include imprisonment, fines and denial of insurance benefits.

A C O R D 1 (2013/01) Page 3 of 3

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Exhibit P2

y\CORE> AUTOMOBILE L O S S NOTICE D A T E ( M M ; D D A T Y Y )

A G E N C Y I N S U R E D L O C A T I O N C O D E D A T E O F L O S S A N D T I M E

1 AM

PM

A G E N C Y

CARRIER N A I C C O D E

A G E N C Y

P O L I C Y N U M B E R

C O N T A C T N A M E :

P O L I C Y N U M B E R

P H O N E ( A / C . No. Ext):

P O L I C Y T l ' P E

F A X ( A ( C . No):

P O L I C Y T l ' P E

E - M A I L A D D R E S S :

C O D E : S U B C O D E :

A G E N C Y C U S T O M E R I D :

INSURED

N A M E OF I N S U R E D (First, Middle, Last) I N S U R E D ' S M A I L I N G A D D R E S S

D A T E OF B I R T H FEIN (If applicable) M A R I T A L S T A T U S / C I V I L U N I O N (if applicable)

I N S U R E D ' S M A I L I N G A D D R E S S

P H O N E " * • • B U S • C E L L P H O N E * * " ^ • H O M E • B U S • C E L L P R I M A R Y E - M A I L A D D R E S S : P H O N E " * • • B U S • C E L L P H O N E * * " ^ • H O M E • B U S • C E L L

S E C O N D A R Y E - M A I L A D D R E S S :

CONTACT CONTACT INSURED

N A M E OF C O N T A C T (First, Middle, Last) C O N T A C T S M A I L I N G A D D R E S S

P H O N E " * • • B U S • C E L L P H O N E S * " ^ • H O M E • B U S • C E L L

C O N T A C T S M A I L I N G A D D R E S S

W H E N T O C O N T A C T P R I M A R Y E - M A I L A D D R E S S :

W H E N T O C O N T A C T

S E C O N D A R Y E - M A I L A D D R E S S :

L O S S LOCATION O F L O S S

S T R E E T :

P O L I C E OR F IRE DEPARTMENT CONTACTED

C i n ' , S T A T E , ZIP: R E P O R T NUMBER

COUNTRY:

R E P O R T NUMBER

D E S C R I B E LOCATION OF L O S S IF NOT A T S P E C I F I C S T R E E T A D D R E S S :

DESCRIPTION O F ACCIDENT (ACORD 101, Additional Remarks Schedule, may be attached if more space Is required)

INSURED V E H I C L E V E H * Y E A R MAKE:

BODY T Y P E :

P L A T E NUMBER S T A T E

MODEL: V.I.N.:

OWNER'S NAME AND A D D R E S S (Check If same as Insured) P H O N E " * • HOME • BUS • C E L L T p E g O N D A R Y | - - | no^g Q B U S • C E L L

PRIMARY E-MAIL A D D R E S S :

S E C O N D A R Y E-MAiL A D D R E S S :

DRIVER'S NAME AND A D D R E S S (Check If same as owner) P H O N E " * • • B U S • C E L L p ^ g ^ ^ ' ^ ^ ' ' ^ • H O M E • B U S • C E L L

PRIMARY E-MAIL A D D R E S S ;


RELATION TO INSURED (Employee, family, etc.)

DATE OF BIRTH DRIVER'S L I C E N S E NUMBER S T A T E P U R P O S E OF U S E U S E D WITH PERMISSION? (Y/N)

D E S C R I B E DAMAGE

1. WAS A STANDARD CHILD PASSENGER RESTRAINT SYSTEM (CHILD SEAT) INSTALLED IN THE VEHICLE AT THE TIME OF THE ACCIDENT?

2. WAS THE CHILD PASSENGER RESTRAINT SYSTEM (CHILD SEAT) IN USE BY A CHILD DURING THE TIME OF THE ACCIDENT?

3. DID THE CHILD PASSENGER RESTRAINT SYSTEM (CHILD SEAT) SUSTAIN A LOSS AT THE TIME OF THE ACCIDENT?

ESTIMATE AMOUNT; W H E R E CAN V E H I C L E B E S E E N ? ; WHEN CAN V E H I C L E B E S E E N ? :

OTHER INSURANCE ON V E H I C L E - C A R R I E R : POLICY NUMBER:

A C O R D 2 (2013/01) Page 1 of 4 © 1988-2013 A C O R D CORPORATION. All rights reservecJ.

The A C O R D name and logo are registered marks of A C O R D

47

OTHER V E H I C L E / P R O P E R T Y DAMAGED N O N - V E H I C L E ? AGENCY CUSTOMER ID:

V E H # Y E A R MAKE: BODY T Y P E :

P L A T E NUMBER S T A T E

MODEL: V.I.N.:

D E S C R I B E P R O P E R T Y (Other Than Vehicle) O T H E R VEH/PROP INS? (Y/N)

C A R R I E R OR A G E N C Y NAME POLICY NUMBER

I ^ O f ^ • HOME • B U S • C E L L I P^SSE*' "^ • HOME • B U S • C E L L DINNER'S NAME AND A D D R E S S

PRIMARY E-MAIL A D D R E S S ;

S E C O N D A R Y E-MAIL A D D R E S S ;

DRIVER'S NAME AND A D D R E S S (Check if same as owner) P H O N E ' J • • B U S • C E L L p ^ g ^ ^ ^ / ^ ^ • H O M E • B U S • C E L L

PRIMARY E-MAIL A D D R E S S :

S E C O N D A R Y E-MAiL A D D R E S S :

D E S C R I B E DAMAGE

ESTIMATE AMOUNT W H E R E CAN DAMAGE B E S E E N ?

INJURED

NAME & A D D R E S S PHONE (A/C, No) P E D INS VEH

OTH VEH A G E E X T E N T OF INJURY

• • •

• • •

• • •

• • •

W I T N E S S E S OR P A S S E N G E R S

NAME & A D D R E S S PHONE (A/C, No) INS

VEH OTH VEH OTHER (Specify)

• •

• •

• •

R E P O R T E D BY R E P O R T E D TO

R E M A R K S (ACORD 101, Additional Remarks Schedule, may be attached if more space is required)

A C O R D 2 (2013/01) Page 2 of 4

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AGENCY CUSTOMER ID:

APPLICABLE IN ALABAMA

Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or who knowingly presents false information in an application for insurance is guilty of a crime and may be subject to restitution fines or confinement in prison, or any combination thereof.

APPLICABLE IN ALASKA

A person who knowingly and with intent to injure, defraud, or deceive an insurance company files a claim containing false, incomplete, or misleading information may be prosecuted under state law.

APPLICABLE IN ARIZONA

For your protection, Arizona law requires the following statement to appear on this form. Any person who knowingly presents a false or fraudulent claim for payment of a loss is subject to criminal and civil penalties.

APPLICABLE IN ARKANSAS, DELAWARE, KENTUCKY, LOUISIANA, MAINE, MICHIGAN, NEW J E R S E Y , NEW MEXICO, NORTH DAKOTA, PENNSYLVANIA, RHODE ISLAND, SOUTH DAKOTA, TENNESSEE,

TEXAS, VIRGINIA, AND WEST VIRGINIA

Any person who knowingly and with intent to defraud any insurance company or another person, files a statement of claim containing any materially false information, or conceals for the purpose of misleading, information concerning any fact, material thereto, commits a fraudulent insurance act, which is a crime, subject to criminal prosecution and civil penalties. In LA, ME, TN, and VA, insurance benefits may also be denied.

APPLICABLE IN CALIFORNIA

For your protection, California law requires the following to appear on this form: Any person who knowingly presents a false or fraudulent claim for payment of a loss is guilty of a crime and may be subject to fines and confinement in state prison.

APPLICABLE IN COLORADO

It is unlawful to knowingly provide false, incomplete, or misleading facts or information to an insurance company for the purpose of defrauding or attempting to defraud the company. Penalties may include imprisonment, fines, denial of insurance, and civil damages. Any insurance company or agent of an insurance company who knowingly provides false, incomplete, or misleading facts or information to a policy holder or claimant for the purpose of defrauding or attempting to defraud the policy holder or claimant with regard to a settlement or award payable from insurance proceeds shall be reported to the Colorado Division of Insurance within the Department of Regulatory Agencies.

APPLICABLE IN THE DISTRICT OF COLUMBIA

Warning: It is a crime to provide false or misleading information to an insurer for the purpose of defrauding the insurer or any other person. Penalties include imprisonment and/or fines. In addition, an insurer may deny insurance benefits, if false information materially related to a claim was provided by the applicant.

APPLICABLE IN FLORIDA

Pursuant to S. 817.234, Florida Statutes, any person who, with the intent to injure, defraud, or deceive any insurer or insured, prepares, presents, or causes to be presented a proof of loss or estimate of cost or repair of damaged property in support of a claim under an insurance policy knowing that the proof of loss or estimate of claim or repairs contains any false, incomplete, or misleading information concerning any fact or thing material to the claim commits a felony of the third degree, punishable as provided in S. 775.082, S. 775.083, or S. 775.084, Florida Statutes.

APPLICABLE IN HAWAII

For your protection, Hawaii law requires you to be informed that presenting a fraudulent claim for payment of a loss or benefit is a crime punishable by fines or imprisonment, or both.

APPLICABLE IN IDAHO

Any person who knowingly and with the intent to injure, defraud, or deceive any insurance company files a statement of claim containing any false, incomplete or misleading information is guilty of a felony.

APPLICABLE IN INDIANA

A person who knowingly and with intent to defraud an insurer files a statement of claim containing any false, incomplete, or misleading information commits a felony.

A C O R D 2 (2013/01) Page 3 of 4

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AGENCY CUSTOMER ID:

APPLICABLE IN KANSAS

Any person who, knowingly and with Intent to defraud, presents, causes to be presented or prepares with knowledge or belief that it will be presented to or by an insurer, purported insurer, broker or any agent thereof, any written statement as part of, or in support of, an application for the issuance of, or the rating of an insurance policy for personal or commercial insurance, or a claim for payment or other benefit pursuant to an insurance policy for commercial or personal insurance which such person knows to contain materially false information concerning any fact material thereto; or conceals, for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act.

APPLICABLE IN MARYLAND

Any person who knowingly or willfully presents a false or fraudulent claim for payment of a loss or benefit or who knowingly or willfully presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison.

APPLICABLE IN MINNESOTA A person who files a claim with intent to defraud or helps commit a fraud against an insurer is guilty of a crime.

APPLICABLE IN NEVADA

Pursuant to NRS 686A.291, any person who knowingly and willfully files a statement of claim that contains any false, incomplete or misleading information concerning a material fact is guilty of a felony.

APPLICABLE IN NEW HAMPSHIRE

Any person who, with purpose to injure, defraud or deceive any insurance company, files a statement of claim containing any false, incomplete or misleading information is subject to prosecution and punishment for insurance fraud, as provided in RSA 638:20.

APPLICABLE IN NEW YORK

Any person who knowingly and with intent to defraud any insurance company or other person files an application for commercial insurance or a statement of claim for any commercial or personal insurance benefits containing any materially false information, or conceals for the purpose of misleading, information concerning any fact material thereto, and any person who in connection with such application or claim knowingly makes or knowingly assists, abets, solicits or conspires with another to make a false report of the theft, destruction, damage or conversion of any motor vehicle to a law enforcement agency, the Department of Motor Vehicles or an insurance company, commits a fraudulent insurance act, which is a crime, and shall also be subject to a civil penalty not to exceed five thousand dollars and the value ofthe subject motor vehicle or stated claim for each violation.

APPLICABLE IN OHIO

Any person who, with intent to defraud or knowing that he/she is facilitating a fraud against an insurer, submits an application or files a claim containing a false or deceptive statement is guilty of insurance fraud.

APPLICABLE IN OKLAHOMA

WARNING: Any person who knowingly and with intent to injure, defraud or deceive any insurer, makes any claim for the proceeds of an insurance policy containing any false, incomplete or misleading information is guilty of a felony.

APPLICABLE IN WASHINGTON

It is a crime to knowingly provide false, incomplete, or misleading information to an insurance company for the purpose of defrauding the company. Penalties include imprisonment, fines and denial of insurance benefits.

A C O R D 2 (2013/01) Page 4 of 4

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Exhibit P3

Revised 07/01/14

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RE: JPA Member:

Date of Loss:

Location:

Coverage:

CWC File:

In order to process this claim, the following additional information is necessary: _____ Proof of purchase (original invoice, purchase order, etc.) _____ Police Report (will save time and expense) _____ Repair Estimate re school property _____ Replacement Property Invoice _____ Proof of Repairs (e.g. “Paid” receipt) re school property _____ Other:

Please notify us regarding any recovery of property or restitution from the responsible party. If you have any questions, please contact the undersigned. Very truly yours,