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Last Modified: 08--2016 [jqja] <br />State Farm® <br />Business Insurance (Fire Only) <br />Workers’Compensation Waiver of Subrogation Questionnaire <br />Date: <br />Policyholder Name: <br />Policy Number: <br />Agent: <br />Please review the following: <br />x For new waivers, the contract for work between the policyholder and the party requesting the <br />Waiver should be reviewed (by Underwriting or Agency) to verify a ‘written contract’ actually <br />exists and a Waiver of Subrogation is specifically required for Workers’ Compensation. <br />1. Has the contract been reviewed and is the Waiver of Subrogation required? Yes No <br />2. What is the relationship between our Insured and the party requesting the Waiver of Subrogation? <br />Describe the work or services being performed. <br />3. Name and Mailing Address of party to be named on Waiver of Subrogation: <br />4.Effective Date of the endorsement: <br />x Contract START Date: _____________________________ <br />x Contract END Date: ______________________________ <br />5.Cost of Contract/Payroll: ____________________________________ <br />Good City Company <br />97-MB-F672-8 <br />Gina Vallee, License # 0B67587 <br />✔ <br />Consultant providing contract planning and other municipal services. <br />City of Pleasanton <br />P.O. Box 520 <br />Pleastanton, CA 94566 <br />5/21/2025 <br />5/21/2026 <br />$ 55,000 <br />Docusign Envelope ID: E4EAE9C2-E769-48F6-B15F-C0F0C2D22D14