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WAIVER OF SUBROGATION NOTICE <br />Enclosed is your copy of a certificate of insurance on which the certificate holder <br />required a waiver of subrogation: <br />1. 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 />$5,000.00 <br />13.30°s <br />$ 665.00 <br />3.00% <br />$ 19.95 <br />684.95 (665.00 + 19.95) <br />Rkk M...g„w Dn <br />(A �er�cnnRw�er: <br />91:1 li ' %biC �ILWOn <br />Ruk Mart�9rnm. pitic.lAitle <br />