PBSci Personnel/Payroll
5th Floor Physical Sciences Building
Mail Stop: PB Sci. Pers/Pay Res. Acctg.
Fax: 831-459-5599

Volunteer Agreement: Election of Workers' Comp Coverage

• Volunteer Guidelines
• Volunteer Agreement: Letter
• Volunteer Agreement: Election of Workers' Comp Coverage
• Volunteer Monthly Roster
  

VOLUNTEER AGREEMENT: ELECTION OF WORKERS' COMPENSATION COVERAGE
Download this information: PDF

UNIVERSITY OF CALIFORNIA, SANTA CRUZ — UCSC

(For use by persons not employed by UCSC who are providing volunteer services for UCSC benefit)

NAME OF VOLUNTEER: _________________________________ SOCIAL SECURITY NO: ________________

DATE OF BIRTH: ___________________ SEX: M_____ F_____ HOME PHONE: (      ) __________________

HOME ADDRESS: ____________________________________________________________________________________________

UCSC DEPARTMENT FOR WHICH VOLUNTEER SERVICES WILL BE PROVIDED: ______________________

START DATE: _________________________________         END DATE: ______________________________

NAME OF UCSC EMPLOYEE SUPERVISING VOLUNTEER: __________________________________________
CAMPUS PHONE: ________________

ELECTION OF REMEDY

As a condition of my participation in UCSC volunteer service and in consideration for my use of UCSC facilities and equipment, I, the above named volunteer, hereby understand and agree that in the event I am injured or contract an illness or disease either during my UCSC volunteer service, or subsequent thereto as a result of such service, that I am hereby electing to be covered under the University of California’s Self Insured Workers’ Compensation Program as a volunteer for the University of California, Santa Cruz Campus, and that the benefits provided by the Labor code of the State of California shall be my SOLE AND EXCLUSIVE REMEDY FOR ANY AND ALL SUCH INJURIES, ILLNESSES OR DISEASES. This election of remedy shall be binding on myself, my heirs, administrators, executors and assigns.

WAIVER, RELEASE, & INDEMNITY

In consideration of my use of UCSC facilities and equipment and of my coverage under the University’s Self Insured Worker’s Compensation Program I, the above name Volunteer, hereby for myself, my heirs, executor, administrators, and assigns voluntarily release, forever discharge, waive, and relinquish any and all actions, claims, or causes of action for bodily injury, personal injury, property damage, or wrongful death occurring or arising out of the course and scope of my volunteer service against The Regents of the University of California, its officers, agents, volunteers, and/or employees (herein after referred to as the University), whether the same shall arise by contract, the negligence of any said persons, or otherwise. IT IS MY INTENTION BY THIS INSTRUMENT TO EXEMPT AND RELIEVE THE UNIVERSITY FROM ANY AND ALL LIABILITY TO ME, MY HEIRS, ADMINISTRATORS, EXECUTORS AND ASSIGNS FOR BODILY INJURY, PROPERTY DAMAGE, AND WRONGFUL DEATH CAUSED BY NEGLIGENCE.

I, the above named Volunteer, for myself, my heirs, my administrators, executors and assigns do hereby agree, in the event any claim for bodily injury, property damage or wrongful death arising out of my volunteer services shall be prosecuted against the University, to defend, indemnify, and hold harmless the University from and against any and all such claims or causes of action by whomever or wherever made or presented, except for such claims as may arise from or be caused by the willful misconduct of the University.

I, the above named Volunteer, hereby expressly waive all rights under Section 1542 of the Civil Code of California which states that a "general release does not extend to claims which the creditor does not know or suspect to exist in his favor at the time of executing the release which if known by him must have materially affected his settlement with the debtor."

REPORTING OF INJURIES/ILLNESSES AND MEDICAL TREATMENT

I hereby agree to report all injuries or illnesses contracted in the scope of my UCSC volunteer service to the UCSC Department in which I am providing volunteer service and to the Office of Risk and Insurance Management (831-459-2850, fax 831-459-3268), 1156 High Street — H Barn, Santa Cruz, CA 95064 immediately. Volunteers injured on the campus are only authorized to be treated at (1) Cowell Student Health Center (weekdays 8:30 — 4:30), (2) Dominican Occupational Health Center, 610 Frederick St., Santa Cruz (831) 457-7118 (weekdays 8:00 to 4:30) or (3) Dominican Hospital Emergency Room (after hours).

I, the above named volunteer, have read and understand the above "election of remedy," the "waiver, release and indemnity," and the waiver of Civil Code Section 1542 rights, and agree to all of them.

Signature of Volunteer: ______________________________________ Date: __________________

Signature of Supervisor: _____________________________________ Date: __________________

Original: Volunteer’s Department (Retain for 18 months following termination of volunteer services): Copies: (1) Volunteer, (2) Insurance and Risk Management

ALSO COMPLETE THE Volunteer Agreement: Letter