Additional Insured Request Form

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

 

ADDITIONAL INSURED REQUEST FORM

Insured's Information

Insured Business Name

Insured Lic. No.

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

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

****************************************************

PLEASE MAKE SURE TO FILL OUT THIS FORM COMPLETELY