Sample Form 2: Workers Compensation Waiver Subrogation

Liability & Insurance 750

Sample Form 2 Workers Compensation Waiver Subrogation

View enlarged version of this image

Designated Organization -	The full name of the Additional Insured as shown in the Insurance Exhibit should be entered here. It is also acceptable if the “as required by contract” language is used. The endorsement is not enforceable if this not filled in.

Designated Organization -

The full name of the Additional Insured as shown in the Insurance Exhibit should be entered here. It is also acceptable if the “as required by contract” language is used. The endorsement is not enforceable if this not filled in.