Sample Forms

Sample Form Below are examples and explanations of common forms used in conjunction with insurance requirements on contracts.

Index of Forms

Auto
- Auto Liability Pollution (Sample Form 12)
- Evidence of Insured Status (Sample Form 15)
- MCS-90 (Sample Form 11)
Additional Insured
- Completed Operations (Sample Form 5)
- Designated Person or Organization (Sample Form 7)
- Engineers, Architects or Surveyors not Engaged by the Named Insured (Sample Form 16)
- Managers or Lessors of Premises (Sample Form 9)
- Ongoing Operations (Sample Form 4)
- Ongoing and Completed Operations (Sample Form 6)
- Owners, Lessees or Contractors - Automatic Status When Required in Construction Agreement (Sample Form 18)
- Permits (Sample Form 13)
- Vendors (Sample Form 8)
Certificates of Insurance
- Certificate of Liability Insurance (Sample Form 1)
- Certificate of Property Insurance (Sample Form 10)
Primary and Non-contributory
- Primary and Non-contributory (Sample Form 14)
Waivers of Subrogation
- General Liability Waiver of Subrogation (Sample Form 3)
- Workers' Comp Waiver of Subrogation (Sample Form 2)
Workers' Compensation
- Declaration of “No Employees” (Sample Form 17)
- Workers' Comp Waiver of Subrogation (Sample Form 2)

Jamie Bloom, Insurance Manager
Reesha Ruel, Liability Manager

Risk Management Division

Human Resources Department

Business Hours

Address

575 Administration Drive

Room 116 B

Santa Rosa, CA 95403

38.465237, -122.725363