ADDITIONAL INSURED REQUEST FORM

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ADDITIONAL INSURED REQUEST FORM

Insured's Information

Insured Business Name

Insured Lic. No. (if applicable)

Insured Contact No.

Insured E-mail Address

Additional Insured Info

1. Name(s) of Entity requesting to be added as an Additional Insured

2. Certificate Holder Name, Address & Fax No./ Email of entity requesting to be added as an Additional Insured

Name

Street

City/State/Zip

Additional Insured E-mail Address/Fax#

3. Explain the relationship between the insured and additional insured (G.C., Owner. Etc)

4. Type of work to be done for/with the Additional Insured (Please be specific ):

If no work is being done by your company, please advise what the certificate is needed for(Permit, Landlord, Rental Equipment, etc.)

5. Is this a Residential Project? (Y / N)

6. Is this a Commercial Project? (Y / N)

If so, what type of Commercial Building (School, Retail, Office, etc.)

7. Are there multiple jobsites? (Y / N )

If so, please provide the cities or counties :

8. If there is only one job site, please provide the address :

Job Site Street

City/State/Zip

9. Length of job(s) :

Anticipated start date :

10.Contract Amount or Job Value:

Upload File Attachment

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PLEASE MAKE SURE TO FILL OUT THIS FORM COMPLETELY

Please Feel free to download the ADDITIONAL INSURED REQUEST FORM here.

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