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NJ DCF Logo with reverse copy

 

New Jersey Department of Children and Families Policy Manual

 

Manual:

DCF

Department of Children & Families

Effective Date:

Volume:

X

Forms

Chapter:

A

Forms

10-22-2012

Subchapter:

1

Forms

Issuance:

16.78

DCF Form 16-78, Insurance and Indemnification Request

 

Click here to view, complete, or print DCF Form 16-78.

 

WHEN TO USE IT

 

In arranging for sites for various activities, DCF staff may be asked to provide information about liability insurance. The State of New Jersey is self-insured and does not carry public liability insurance. The obligation of the State to be responsible for legitimate tort claims is covered under the terms and provisions of the New Jersey Tort Claims Act.

 

The Insurance and Indemnification Request, DCF Form 16-78, is completed by the Administrative Assistant or designee, signed by the Local Office Manager/Area Director, and sent to the Bureau of Risk Management whenever there is a request for insurance information. The Bureau of Risk Management, in turn, sends the facility a letter regarding insurance and indemnification.

 

When filling out an application for usage of space, the response to any question regarding insurance is, "State of New Jersey-Self-Insured."

 

HOW TO USE IT

 

DCF Form 16-78 is a template. Use the "tab" key to maneuver from text field to text field. Complete each field as noted. Use Local Office Letterhead. Complete the information requested regarding the event and the request for insurance and indemnification. Send the completed form to the Department of Treasury, Bureau of Risk Management. Send as soon as the request is made, but no later than 10 working days before the event. Use interoffice mail to send the original. Forward a copy to the Office of Legal and Regulatory Liaison (OLRL).

 

DISTRIBUTION

 

Original          -           Director, Bureau of Risk Management

 

Copy               -           Local Office Manager/Area Director

 

Copy               -           OLRL