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 ?
Does the Additional Insured maintain primary insurance to cover exposures at the job location?
Has a modified blanket additional Insured already been added to this policy?
Additional request. Select options below:

Additional charges will apply
Primary/Non-contributory wording is required
Waiver of Subrogation is required
Additional insured with completed operations cg2037 is required (Available for commercial work only)
Modified blanket additional insured required – covers up to 5 – each additional insured must be reported and approved by underwriting.
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
Coverage requested effective date

MonthDayYear
Date
Signature of Insured
*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: