Forms and Waivers

All forms and waivers require Adobe Acrobat. If you do not have Adobe Acrobat, please click here

Complete and fax Requests for Certificates of Insurance, Hold Harmless Agreements, and Facility Use Agreements to the Risk Services Office at (530) 756-1113.

For questions regarding the processing and/or submittal of a form or waiver, contact Linda Harris at:

(530) 750-1263

olharris@ucanr.edu

Forms for Facility Use Agreements

Attachment A: Preferred Hold Harmless and Indemnification Clause

If a facility use agreement contains a clause that compromises The Regents' assets by leaving open the potential for lawsuits from any and all parties, the County Director or Regional Director need to review the language and negotiate changes to the contract language.

Attachment B: Alternate Hold Harmless and Indemnification Clause

If a facility use agreement contains a clause that compromises The Regents' assets by leaving open the potential for lawsuits from any and all parties, the County Director or Regional Director need to review the language and negotiate changes to the contract language.

Generic Certificate of Self-Insurance
This generic Certificate of Self-Insurance Coverage may satisfy many vendors or agencies who are requesting proof of insurance from the University. We recommend that when a certificate of insurance is requested by a business or organization, that you first provide the above generic Certificate of Self-Insurance. If this generic certificate does not meet the requestor's needs, then proceed to the online or paper Request for Certificate of Insurance below.

Attachment C: Online Request for Certificate of Insurance
To ensure expedited response to your request for a Certificate of Insurance, please use the online request form.

Attachment C: Request for Certificate of Insurance
This paper form is an alternative to online Request for Certificate of Insurance.

Attachment D: Preferred ANR Use Agreement

Use this form as a simple facility use agreement when the business or organization does not have a standard use agreement or contract.

Attachment E: Alternate ANR Use Agreement

Alternate form to use as a simple facility use agreement when the business or organization does not have a standard use agreement or contract.

Negotiated Indemnification Agreements
Agreements with Joint Powers Authorities (JPAs) and state agencies on indemnification language for use of facilities at school districts, community colleges, California State University (CSU) campuses, fairs, etc.

Other Forms

Incident Report (other than employee injury) (pdf) or Incident Report (other than employee injury) (Word)
Any incident resulting in property loss/damage and/or causalities (including property damage, theft, injuries to non-employees, and all auto accidents) must be reported using this form.

Vehicle Insurance/Incident Report Packet

This package of information should be placed in all ANR vehicles to provide proof of insurance, an Incident Report and other forms to use in the event of an automobile accident.

Equipment Loan - UC as Borrower

Equipment Loan - UC as Lender

Volunteer Forms

4-H Volunteer application and enrollment

Master Gardener volunteer application

Master Food Preserver volunteer information

Use the following forms for volunteers in any other ANR programs

ANR Volunteer Information and Waiver

ANR Volunteer Self Disclosure (required if volunteer will work with youth or drive for University business)

Waivers

Elective/Voluntary Activity Waivers

English and in Spanish covering liability issues for elective/voluntary events, including 4-H programs.

DMV Employer Pull Notice enrollment

EPN Employee Notification form

Use this form to enroll the employee in the DMV Employer Pull Notice program when an employee drives a UC or County vehicle for work.