Liability & Insurance

Sample Form 9: Additional Insured – Managers Or Lessors Of Premises

Designation Of Premises (Part Leased To You) - Not acceptable if left blank.  Must show location of premises or “as required by contract”.
Name Of Person(s) Or Organization(s) (Additional Insured) -Not acceptable if left blank.  Must show exact name of the additional insured or “as required by contract”.
Section II - Who Is An Insured -

The following endorsement is acceptable only if we have issued a lease to the party using our premises.  Do not accept this endorsement if we have issued a permit or a license agreement.

Permits and license agreements are different from leases.  In the event of a claim, the insurer might try to deny our additional insured status if the agreement is something other than a lease.

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 arising out of the ownership, maintenance or use of that part of the premises leased to you and shown in the Schedule…

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 - Managers or Lessors of Premises

Sample Form

Image of sample form with field definitions and explanations.