WC Scheduled Waiver of Subrogation Questionnaire

Policy Information

Named Insured

Policy Number

1. Entity Requesting the Waiver

Name of Entity

Street Address

City

State

Zip Code

2. Job Description

Describe the 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 doing, followed by a description of the specific work that the insured performs for the general contractor.

3. Jobs (Up to 5)

Leave any unused job rows blank.

Job 1

Job 1 Name

Street Address

City

State

Zip Code

Job 2

Job 2 Name

Street Address

City

State

Zip Code

Job 3

Job 3 Name

Street Address

City

State

Zip Code

Job 4

Job 4 Name

Street Address

City

State

Zip Code

Job 5

Job 5 Name

Street Address

City

State

Zip Code