ACWA Joint Powers Insurance Authority
GSA Underwriting Application

PROSPECTIVE GROUNDWATER SUSTAINABILITY AGENCY APPLICATION CHECKLIST

Thank you for your interest in the ACWA JPIA Liability Program. To assist you in the evaluation process, below is a checklist of documents that needs to be completed and returned to ACWA JPIA.

PLEASE MAIL COMPLETED APPLICATION TO:

ACWA JPIA

ATTN: MEMBER SERVICES

P.O. BOX 619082

ROSEVILLE, CA 95661-908

Agency Name *

Mailing Address

Agency Contact

Email *

Phone

Agency Formation Date//

Governing Water Code:

ACWA Membership Join Date//

Annual Operating Budget

Total Annual Revenues

List other JPAs of which your agency is a member:

Are there other agencies, authorities, or entities wholly controlled by the Agency?

Current Insurance Carrier or JPA:

Current Coverage Period:

Current Coverage Limit:

Current Retained Limit:

Desired Coverage Date:

During the last five years, has any insurer cancelled, declined, or non-renewed?

Person designated to handle 3rd party liability claims:

Title:

Do you utilize a Third Party Administrator?

Do you have written procedures for:

obtaining claims information
claims follow-up
accident investigation
corrective action

Check all that apply

Describe any pending or expected litigation:

Describe any incurred claims or litigation within the last 10 years NOT covered by insurance, i.e. inverse condemnation, breach of contract, or pollution:

Do you utilize any of the following type of pipe in your system?

Steel/cast iron

Approx. age:

Asbestos

Approx. age:

Plastic/C-900

Approx. age:

Other

Approx. age:

Numbers

Year	Full Time	Part Time	Seasonal	Volunteers

Name

MAILING ADDRESS	MAIN PHONE
P.O. BOX 619082 ROSEVILLE, CA 95661-9082	(916) 786-5742

ACWA Joint Powers Insurance Authority GSA Underwriting Application

PROSPECTIVE GROUNDWATER SUSTAINABILITY AGENCY APPLICATION CHECKLIST

Thank you for your interest in the ACWA JPIA Liability Program. To assist you in the evaluation process, below is a checklist of documents that needs to be completed and returned to ACWA JPIA.

PLEASE MAIL COMPLETED APPLICATION TO:

ACWA JPIA

ATTN: MEMBER SERVICES

P.O. BOX 619082

ROSEVILLE, CA 95661-908

Do you utilize any of the following type of pipe in your system?

ACWA Joint Powers Insurance Authority
GSA Underwriting Application