Sample Form 13: Additional Insured – Permits or Authorizations

Liability & Insurance 750

Sample Form 13 Additional Insured Permits Or Authorizations

State or Governmental Agency or Subdivision or Political Subdivision -	Must show the name of the additional insured or "by contract". Not acceptable if left blank.
Section II - Who is An Insured -	We are protected only if we issued a permit or other authorization. We are not protected if the permittee is doing work FOR us. For that we need Sample Form 4 & 5.

State or Governmental Agency or Subdivision or Political Subdivision -

Must show the name of the additional insured or "by contract". Not acceptable if left blank.

Section II - Who is An Insured -

We are protected only if we issued a permit or other authorization.

We are not protected if the permittee is doing work FOR us. For that we need Sample Form 4 & 5.