Additional Insured Info Request


Please provide the following for each Additional Insured:

Please check off which of the following apply as to their interest:

[ ] Loss Payee [ ] Mortgagee [ ] Additional Interest [ ] Certificate Holder



Fax & Contact Name:

Email & Contact Name:

Phone & Contact Name:

It is very important for you to review your contracts to see if you are required to have any of the following additional coverages for the additional insured:

Waiver of Subrogation

Primary non-contributory wording

They are not normally included in additional insured coverage but are often available for an additional premium as they change the risk.


<<User Name>>
<<Agncy_Address>>, <<Agncy_City>>, <<Agncy_State>>  <<Agncy_Zip>>
Phone:<<Agncy_Phone>>  |  Fax: <<Agncy_Fax>>