WC Blanket Waiver of Subrogation Questionnaire

Policy Information

Policy Number

Named Insured

1. Typical Job Description

Describe a typical job and what the insured will be doing on the job. If the insured is a subcontractor, describe the project that the general contractor is typically doing, followed by a description of the specific work that the insured usually performs for the general contractor.

2. Locations of the Last Few Jobs

Up to 2 lines fit cleanly on the printed form.

3. Out-of-State Travel

Does the insured anticipate traveling out of the state for a job?

Yes No

If yes, where?