Additional Insured Request Form

Additional Insured Request Form

*Please allow 24-48 hours for processing*
Named Insured:*
Company name or First and Last name.
Policy Number: *
Effective Date of Request:*

MonthDayYear
Date
Additional Insured Info
Name:*
Company name or First and Last name.
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Relationship/Interest: *
To The Named Insured
Description of Work:*
Description of work being performed for additional Insured
Specific Job Location:*
Contract Cost:*
E-mail: *
example@example.com
Is there a written contract between the Name Insured and the Additional Insured ?*

YesNo
Does the Additional Insured maintain primary insurance to cover exposures at the job location?*

YesNo
Has a modified blanket additional Insured already been added to this policy?*

YesNo
Additional request. Select options below:

Additional charges will apply
Primary/Non-contributory wording is required

Select
Waiver of Subrogation is required

Select
Additional insured with completed operations cg2037 is required (Available for commercial work only)

Select
Modified blanket additional insured required – covers up to 5 – each additional insured must be reported and approved by underwriting.

Select
Note: Maximum number of days cancellation notice to additional insured: (10) ten underwriter approval is required for additional insured requests.
Contact National Insurance Associates Inc for details on the additional charges
Signature*

Clear
Coverage requested effective date*

MonthDayYear
Date
Signature of Insured*

Clear
*Once signed and requested, all additional premiums are fully earned.
Should be Empty:

Additional Insured Request Form

Additional Insured Info

Additional request. Select options below: