Liability & Insurance

Sample Form 7: Additional Insured – Designated Person or Organization

Name Of Additional Insured Person(s) Or Organization(s) -Not acceptable if left blank. Must show the name of the additional insured or “by contract”.
This additional insured endorsement is acceptable for all situations except when we require additional insured status for completed operations. Sample Form 5 is used for that situation.
A. Section II - Who Is An Insured is amended to include as an additional insured:"in the performance of your ongoing operations; or in connection with your premises owned by or rented to you."

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 – Designated Person or Organization

Sample Form

Image of sample form with field definitions and explanations.