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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 : $5 , 000 . 00 <br /> Sample Rate : 13 . 300 <br /> Regular Premium equals : $ 665 . 00 <br /> Surcharge : 3 . 000-. <br /> Additional Waiver charge : $ 19 . 95 <br /> Total premium equals $ 684 . 95 ( 665 . 00 + 19 . 95) <br />