W. Brown & Associates: Additional Insured Request

Property & Casualty

Additional Insured Request Form

Email address*:
Agent Name:
Insured Name:
Policy number*:
Additional Insured:
	Additional Insured Address:
	What is the description of operations of the Additional Insured?
	Exact description of work Insured will be doing for the certificate holder:
	Type of work: Commercial Work Residential Work Commercial & Residential Work
	If it is Residential Work, is the Insured working on any new residential homes, tracts, condos, townhomes or apartments? Yes No
Number of Units:
Job Cost:
Job Duration:
Contract Number:
Project Name:
	Project Location:
	Does Certificate Holder require 30 days notice of cancellation? Yes No
	Does Certificate Holder require "endeavor to" wording crossed out? Yes No
	Is Primary Wording required? Yes No
	Is Non-Contributory Wording required? Yes No
	Is the CG 20 10 11/85 edition date required? (This endorsement can only be considered if required by contract.) Yes No