CITY OF LOS ANGELES
OFFICE OF THE MAYOR
VOLUNTEER CORPS

VOLUNTEER INSURANCE POLICY

The City of Los Angeles currently provides limited medical coverage for volunteers who are properly enrolled through the Volunteer Corps in the Mayor’s Office.  This specialty coverage applies only if the volunteer has no other insurance, or in excess of any other insurance available to him/her.

EXPLANATION OF COVERAGES
Accident Medical, with certain typical exclusions, pays up to $50,000 annually, $5,000 per incident, for medical treatment for most injuries suffered while participating in volunteer activities.  It pays up to $5,000 for death, loss of limb, or sight according to a schedule.  This insurance does not cover expenses that are paid by Medicare or any other group or individual policy available to the volunteer.

		ACCIDENT REPORTING PROCEDURE
In the event of an injury, the volunteer has the responsibility to immediately notify his/her coordinator of the incident.  If for some reason this is not possible, it should be reported within 24 hours of the next City work day, at which time the coordinator will advise the volunteer on proper reporting procedures.

I understand the coverage of the insurance policy listed above and the accident reporting procedures as they have been explained to me.

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Volunteer Signature				Date

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Print Name

Volunteers under the age of 18, please have your parent/guardian sign and date below.

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Volunteer’s Parent/Guardian Signature			Date