Liability & Insurance

Sample Form 4: Additional Insured – Ongoing Operations

For Ongoing Operations Only - A separate endorsement is needed for Additional Insured - Completed Operations.
Name Of Additional Insured Person(s)
Or Organization(s) -
Not acceptable if left blank.  Must show exact name of the additional insured or “as required by contract”.
Location(s) Of Covered Operations -Not acceptable if left blank.  Must include project description unless the “by contract” language is used.  The location must be the location of the work, not our mailing address.
Section II - Who Is An Insured - The following endorsement is acceptable only if contractor is doing work FOR US: #2. The acts or omissions of those acting on your behalf; in the performance of your ongoing operations for the additional insured(s) at the location(s) designated above.

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

Additional Insured – Owners, Lessees or Contractors – Scheduled Person or Organization

Sample Form

Image of sample form with field definitions and explanations.