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Groundwater Sustainability Agency (GSA) Insurance Coverage Application
Fields marked with * are required. As an alternative, you may also download this form in an adobe acrobat document, fill it out, and either fax it to (916)774-7040 or email it to the Member Services Department.
GSA Information
* Agency Name:
* Agency Address * City
State California * Zip
* Agency Contact:
* Email Address:
* Phone Number: * Agency Formation Date:  
('mm/dd/yyyy' format only)
Current Insurance Carrier or JPA:
Current Coverage Period: Current Coverage Limit:
Current Retained Limit:
* Annual Budget: * Desired Coverage Date:  
('mm/dd/yyyy' format only)
* Names of all participating members within the GSA:
Person designated to handle third party liability claims.
* Name: * Title:
* Describe any pending or expected litigation:
* Number of Directors: * Number of Employees:
* Estimated Annual Payroll (if applicable), including Board of Directors:
* How long have the GSA Board Members been in place?
* Is the Agency in full compliance with the training requirements set forth in AB 1825?
If no, please explain
* Do you have a procedure for maintaining AB 1825 training records:
* Are elected officials and staff trained on the Agency's policy regarding ethics, harassment, and discrimination?
* Do you utilize transfer of risk language in all contracts, i.e. minimum insurance limits, hold harmless, and indemnification provisions?
By clicking on the [Submit] button below, you hereby certify that you are duly authorized on behalf of the entity described above that this application is true, accurate, and complete.
* Name: * Title:
  
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