Excess Liability Program
    As well as the information below, the SELF office must have:

1.
2.
3.
4.

A signed SELF Agreement
A copy of your Board's action authorizing participation in SELF
A copy of your district's most recent liability claims report, if available
By signing the JPA Agreement you commit to three years in the program.
General Questions 
Name Of District 

Mailing Address 
City 
State 
Zip
District's County/District School (CDS) Number 
Main Contact Person 
Title 
Telephone 
Fax 
E-mail 
Alternate Contact Person
Title
Average Daily Attendance
Date Coverage To Be Effective 
Primary JPA 

   
Underlying Insurance
District's Self Insured Retention (Deductible) $1.00 to $
Insurance Company/JPA Name 
Policy Dollar Limit $
  to $
Insurance Company/JPA Name 
Policy Dollar Limit $
  to $

Claims Insurance
 Is Claims Administration Done In-house? 
 Yes No
If No, Name of Administration Agency 
Contact Person 
Contact Phone 
Loss Prevention
Does The District Have A Formal Loss Prevention Program? 
 Yes No
If Yes, Is The Program Administered By Internal Staff? Yes No
If No, Name Of External Provider 
External Provider Contact 
External Provider Phone 
Does The District Maintain A Security Or Police Officer? 
 Yes No
Are Outside Contractors Used For This Service?  Yes No

 Number Of Campuses (enter number of campuses in district in the following categories)
Elementary Schools 

Junior High Schools  
High Schools 
Community Colleges 
Other Sites 

 Number Of Vehicles (enter number of vehicles owned by the District in the following categories)
Type 1 Buses (60 - 90 Passengers) 

Type 2 Buses (24 - 28 Passengers) 
Other Vehicles 

Repair Classes
Does The District Provide Auto Repair Classes?
Yes No
Does The District Provide Aircraft Repair Classes?
Yes No

Location
Classify The District Location  Urban Suburban Rural

Other Programs
Has The District Approved Any Charter Schools? Yes No
Are There Applications For Charter Schools Pending? Yes No