Additional Insured Addendum
 
 
 
 
 
 
Please complete one form for each additional insured you are contractually required to list.
 
 
 
 
Policyholder First Name*
 
 
Policyholder Last Name*
 
 
 
Policyholder's Business Name*
 
 
 
 
Address*
 
 
City*
 
 
 
State*
 
 
ZIP Code*
 
 
 
Phone (xxx) xxx-xxxx*
 
 
Email*
 
 
 
 
 
 
Additional Insured Name*
 
 
 
 
Address*
 
 
City*
 
 
 
State*
 
 
ZIP Code*
 
 
 
 
 
 
This Additional Insured addendum provides the additional insured rights of notification under Policy provisions. For additional questions related to coverage, please refer to the named insured’s Policy.