Liability & Insurance

Sample Form 5: Additional Insured – Owners, Lessees Or Contractors – 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 And Description Of Completed 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 protects us only if the contractor is doing work for us: Section II: Who Is An Insured is amended to include as an additional insured the person(s) or organization(s) shown in the Schedule, but only with respect to liability for "bodily injury" or "property damage" caused, in whole or in part, by "your work" at the location designated and described in the Schedule of this endorsement performed for that additional insured and included in the "products-completed operations hazard".

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 – Completed Operations

Sample Form

Image of sample form with field definitions and explanations.