Questionnaire

Please fill out this form to address any additional insured individuals that you wish to add to an existing insurance policy.

Named Insured:
Email Address:
Policy No:

Name of entity requesting to be added as an additional insured:
Operations of entity requesting to be added as Additional insured:
Explain relationship between Named insured and Additional insured:
Type of work to be done for the Additional Insured:
Is there a written contract between the Named Insured and the Additional Insured? Yes No
Contract cost to be done for the Additonal Insured:
Does the Additonal insured maintain primary insurance to cover the exposure or risk? Yes No