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Insurance Exception Evaluation Report
California Maritime Academy
Safety & Risk Management
Insurance Exception Report
Document # AF09-003-001-001
Revision: 001_11.2016
Page 1 of 2
Event/Activity Title
Responsible Person
Department
Date of Event/Activity
Campus Wide
Contract/Vender
Contract/ PO#
Determine the risk and subsequent losses from activities under the contract
1
What activities will take place?
2
Who could be harmed? ( i.e. University
personnel, students, contractor’s personnel,
general public)
3
Are crowds or bystanders likely to be
involved?
YES NO
IF YES, Please explain
4
What property could be damaged?
5
Is there a possible pollution exposure?
YES NO
IF YES, Please explain
6
Will inherently dangerous activity be
involved?
YES NO
IF YES, Please explain
7
How likely is it that the University will be a
defendant in the event of a loss?
LOW/ REMOTE
<2%
Chance of occurrence
MEDIUM / POSSIBLE
2% 25%
Chance of occurrence
HIGH/ PROBABLE
>25%
Chance of occurrence
Based upon the preceding Risk Identification and Evaluation, The Campus is amending standard practices described
in Executive Order No. 849 with regard to Insurance Requirements. The Exception Requested is indicated below.
1
Exception to insurance coverage
requirement.
AL
GL
WC
Other
From
To
2
Exception to AM Best Rating.
AL
GL
WC
Other
From
To
3
Exception to insurance minimum limits.
AL
GL
WC
Other
From
TO
4
Exception to indemnification or endorsement
requirements.
AL
GL
WC
Other
From
To
5
Other Notes
Approvals
Procurement/Contracts
(name)
(signature)
(date)
Risk Management
(name)
(signature)
(date)
Insurance Exception Evaluation Report
California Maritime Academy
Safety & Risk Management
Insurance Exception Report
Document # AF09-003-001-001
Revision: 001_11.2016
Page 2 of 2
RISK MATRIX
REQUIRES RM REVIEW. YES ANSWERS ARE REQUIRED DOCUMENTS. SUBMIT DOCUMENTS TO RM FOR REVIEW.
LOW RISK ACTIVITY. RM REVIEW NOT REQUIRED.
Event/Activity Type
Written
Contract is
required;
no
exceptions
Buyer to verify
CSU General
Insurance
Provisions
have been
met
Additional Insured Endorsement
(AIE) Required
30 day
written
notice of
cancellati
on
endorsem
ent
AM Best
Rating of
no less
than an
A
Comments
1
Guest
Lecturer/Musician/Model
Program/Article Evaluator
Reviewer/Appraiser/Editor
Translator
* Independent Contractors
NO YES or NO
N/A for AIE
YES - Insurance provided.
Attach COI to PO
NO - Insurance not provided. Complete
and sign the form below indicating
event/activity is low risk and insurance is
being waived. Attached the signed Risk
Matrix form to the PO.
N/A N/A
*Independent Contractors - If the
service provided exceeds $4,000, a
Risk Evaluation Form is required and
must be approved by Risk
Management. In addition, the IC
agreement is required and must be
attached to PO.
2
Guest Lecturer/Speaker High
Risk
YES YES YES - REQUIRES RM REVIEW YES YES
Subject matter is considered
controversial or sensitive and may
trigger crowd control issues.
3
Transportation -
Bus/Chartered services
YES
Pre-approved
companies
only via
Purchasing.
YES
In addition, limit
on Auto Liability
must be $5
million; Umbrella
policy must
cover Auto
Liability if limit is
less than $5
million.
YES
General Liability AIE form CG2026 form
or a blanket endorsement form is
acceptable; Designated Auto
Endorsement form CA2048 or its
equivalent.
YES YES
Waiver of Subrogation on GL and
WC required; Primary and Non-
Contributory language required.
4
Armored Car Services YES YES YES
5
Construction (JOC) - Activity
that involves significant
alterations to real property
(buildings) or fixed property
permanently attached to the
building structure.
YES
YES
YES
Increased insurance limits may be
required depending on the scope of
work. The following AIE forms are
required for GL: CG2010 - to cover
ongoing operations and CG2037 to cover
the completed operations;
WC: Waiver of Subrogation form.
Equivalent forms are acceptable.
YES YES
If any of the endorsement forms are
missing, submit to RM for review.
6
Specialized Equipment -
Cranes, Backhoes, and other
types of construction
equipment
YES YES YES YES
7
Hazardous Waste YES YES
YES
Same forms as JOC plus the MCS-90
endorsement form for hauling hazardous
waste.
YES YES
8
Specialized License (TOSA) -
Activities that requires a
license to perform the
activity. Ex: Architects,
Design Consultants,
Recruiters, Lawyers,
Accountants, Financial
Advice/Planners etc.
YES YES
YES
General Liability AIE form CG2026 form
or a blanket endorsement forms are
acceptable.
No AIE form is required for Professional
Liability.
YES YES
Professional Liability limits -
$1,000,000 per claim/$2,000,000
aggregate is acceptable.
9
Minors - Participants under
the age of 18, overnight
activity etc.
No
However, A
Facility Use
Agreement
may be
required
YES YES - REQUIRES RM REVIEW YES YES
Background check/fingerprinting
and Sexual Abuse & Molestation
insurance may be required
depending on the activity.
1
0
Sports/Athletic activities YES YES - REQUIRES RM REVIEW YES YES
Signed Liability Waivers are required
by participants for non-Cal Maritime
sponsored events.
1
1
Non-
Public Works Services
(non - construction)
YES
Provide
scope of
work to RM
for review
YES
May be waived depending on the scope
of work. RM REVIEW IS REQUIRED FOR
ALL WAIVERS.
May be
waived
depending
on the
scope of
work.
YES
This category applies to any Vendor
who comes on campus to provide a
service. Services may include but
not limited to: maintenance
services such as fax/copier repair,
photographers, equipment set ups
and consultants.
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Completed 16 July 2020

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