Liability & Insurance

Sample Form 17: Workers’ Compensation Declaration

Contact Information

Jamie Bloom, Insurance Manager

Katie MacKay, Liability Manager

Risk Management Division

Human Resources Department

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

Sample Form

Workers Compensation Declaration

Sample Form

Image of sample form with field definitions and explanations.