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Enclosed is your copy of a certificate of insurance on which the certificate holder <br />required a waiver of subrogation: <br />t. Please be advised that a waiver of subrogation requires that a 3% surcharge <br />will be applied by State Fund ONLY to the premium assessed on the payroll <br />of your employees earned while engaged in work for that certificate holder <br />who requested the waiver. (Note; if you have no employee payroll on that job, <br />then there is no charge.) <br />2. To apply the 3% surcharge, you must also agree to maintain accurately <br />segregated payroll records for employees engaged in work on job/s for the <br />certificate holder who has the waiver. The payroll records are subject to <br />verification by an auditor. <br />Example: <br />Payroll for job: <br />Sample Rate: <br />Regular Premium equals: <br />Surcharge: <br />Additional Waiver charge: <br />Total premium equals <br />$5,000.00 <br />13.30%- <br />---------- <br />$ <br />3.30%$ 665.00 <br />3.00% <br />$ 684.95 (665.00 + 19.95) <br />REVIEWED BV: '�^`````,`E`UN�IGE HEF2EpIA (PG , OF,+ <br />Lr�u <br />