Liability & Insurance

Sample Form 2: Workers Compensation Waiver Subrogation

Designated Organization -

The full name of the Additional Insured as shown in the Insurance Exhibit should be entered here.  It is also acceptable if the “as required by contract” language is used. The endorsement is not enforceable if this not filled in.

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

Workers Compensation Waiver Subrogation

Sample Form

Image of sample form with field definitions and explanations.