LOS ANGELES UNIFIED SCHOOL DISTRICT
REQUEST FOR PROOF OF SELF-INSURANCE
(EXHIBIT B)
This form is only utilized when a facility/organization requires proof of self-insurance from LAUSD which is
required in a signed agreement, contract or permit.
PLEASE FORWARD SIGNED AGREEMENT, CONTRACT OR PERMIT ALONG WITH THIS REQUEST.
School/Office/LAUSD Location:
Date of Request: Date Certificate is needed:
Reason for Request: [ ] Athletic Tournament [ ] Lease/Rental [ ] Other
(For Field Trips Only): [ ] Pre-Approved Site [ ] Non-Routine Field Trip
(Please forward a copy of the “Request for Approval of School Organized Trip for Students” with this request)
Name/Title (LAUSD Contact):
School/Department/Facility Address:
Phone: ( ) Fax: ( ) E-Mail:
(Please Print Clearly)
Name of Event/Contract/Lease:
(Please provide a copy of any agreement with this request)
Date(s) of Event/Contract/Lease:
Site or location of Event/Lease:
Description of Event/Lease/Rental:
(PLEASE PROVIDE A COMPLETE AND FULL DESCRIPTION OF THE FIELD TRIP, EVENT, LEASE, or GRANT.
THE ACTIVITY MUST MEET THE SAFETY AND RISK STANDARDS OF LAUSD AS ESTABLISHED BY THE OFFICE
OF ENVIRONMENTAL HEALTH & SAFETY (OEHS) AND RISK MANAGEMENT)
Please check: [ ] Inflatable Equipment [ ] Vendor(s) [ ] Street Closure [ ] Carnival Fair [ ] Jumpers
[ ] Aquatic Activities [ ] Animals [ ] Health Fair [ ] Picnic [ ] Other
Certificate Holder Name:
(Name of non-LAUSD organization requesting the certificate)
Certificate Holder Address:
Certificate Holder Phone: ( ) Fax ( ) E-Mail
Contact Person:
An original certificate will be sent to the certificate holder. Please advise if you would like a copy.
Please forward completed form to: Risk Management & Insurance Services – riskfinance@lausd.net
333 South Beaudry Avenue, 28
th
Floor, Los Angeles, CA 90017. FAX (213) 241-8956
10/22/2020
