Requestfor Waiver of Private Organization Liabilityinsurance

REQUESTFOR WAIVER OF PRIVATE ORGANIZATION LIABILITYINSURANCE

PrivateOrganization(PO):

NameofOrg

Name and TitleofIndividualResponsibleforProvidingthis Documentto 55 FSS:

CaptJohnSmith,President

DatethisDocumentReceived by55 FSS:

8December17

Members of Nameof Orghave beenbriefed and understandtheAFI34-223,PrivateOrganization(PO)Program,requiresPOsto buyand maintainadequateinsuranceprotectionagainstclaims and/orlawsuitswhichmayarisefromactivitiesoftheorganizationoritsmembers.Theofficersandmembers ofthisprivateorganizationhavebeen briefedand understandthatthe governmentis notresponsibleforanyclaims thatarisefromtheactivitiesof the organizationoritsmembers.The officersandthe members oftheorganizationunderstandthattheymaybeheldjointlyand severallyliableforanyclaimthatmayarisefromtheactivities ofthisorganization. Attachedis DocumentationofUnderstandingofJointandSeveralLiabilityofObligationsof thisPrivateOrganization,IAW AFI34-223,paragraph10.11.

Name (Printand Signature)ofIndividualResponsible:

President

Recommendapproval.

Date:

AssistantJudge Advocate,55thWing

Date:

Approved.

Commander, 55thMissionSupportGroup

Date:

Attachments:

1.DocumentationofUnderstandingofJointand SeveralLiability.

2.Description ofPO specialfunctions,charitableevents,localfundraisers,orotheractivityPO plans toundertake.

ATTACHMENT1

DOCUMENTATION OFUNDERSTANDING OF JOINTAND SEVERAL LIABILITY FOR OBLIGATIONSOF THIS PRIVATE ORGANIZATION,IAW AFI34-223

Private Organization (PO):Nameof Org

Name and TitleofIndividualResponsibleforProvidingthis Documentto 55 FSS:

CaptJohnSmith,President

DatethisDocumentSubmittedto 55 FSS:

8December2017

MEMBERS OF PRIVATEORGANIZATION

Nameof Org, PLEASE READ

THIS IMPORTANTINFORMATION RELATEDTOYOURMEMBERSHIPIN THIS PRIVATEORGANIZATION

Youmustread AFI34-223PrivateOrganizationsinitsentirety.Bysigningbelow,youacknowledgethatyouhave readthisAFIin itsentirety.

InaccordancewithAFI34-223, paragraph10.11,thisPO musthave liabilityinsurance toprotectagainst claimsand/orlawsuitswhichmayarisefromthe activitiesofthePO oritsmembers,unlesstheInstallationCommander(ordelegate, 55MSG/CC)waivesthisrequirement.

55 MSG/CC maywaive the requirementforcontinuousliabilitycoverage,howeverhe/shemaystillrequireliabilityinsuranceforspecificeventsthatinvolvegreaterriskofinjuryordamage. Insurancewaiversmustbereevaluatedannually. Insuranceshould berequiredunlessthe activitiesof the POare suchthattheriskofliabilityis negligible.

Thegovernmentis notresponsibleforanyclaims thatarisefromthe activitiesofthePO oritsmembers.

As a memberofthisPO,you arejointlyand severallyliablefor theobligations ofthePO. Theabsenceofliabilityinsuranceplaces yourpersonalassetsimmediatelyat risk in theeventofPO liability. Liabilitydependsonthejurisdiction thePO operates in, but generallypertains toinjuryto persons and/ordamageorloss ofproperty.

Yourunderstandingofthesefactmustbedocumented. Therefore, if youunderstandthesefacts,youmustsign and datetherosterbelow.

NAME (PRINTAND SIGN):DATE SIGNED:

CaptJohnSmith

8 December2018

ATTACHMENT2

PRIVATE ORGANIZATION NAME:

JustificationfortheWaiver:

NameofOrg

Name (Printand Signature)ofIndividualResponsible:

CaptJohnSmith

Date:

8December2017

DatethisDocumentReceived by55 FSS:

8 December2017