Liability & Insurance

Sample Form 13: Additional Insured – Permits or Authorizations

State or Governmental Agency or Subdivision or Political Subdivision - Must show the name of the additional insured or "by contract". Not acceptable if left blank.
Section II - Who is An Insured -

We are protected only if we issued a permit or other authorization.

We are not protected if the permittee is doing work FOR us. For that we need Sample Form 4 & 5.

Contact Information

Jamie Bloom, Insurance Manager

Reesha Ruel, Liability Manager

Risk Management Division

Human Resources Department

Business Hours
Monday – Friday
8:00 AM – 5:00 PM
Contact us by Phone
575 Administration Drive
Room 116 B
Santa Rosa, CA 95403
38.465237, -122.725363

Sample Form

Additional Insured - Permits or Authorizations

Sample Form

Image of sample form with field definitions and explanations.