REQUEST FOR PROOF OF INSURED OR ADDITIONAL INSURED

Insurance Holder Information
Name:  Policy#:
Phone:  Email:
Please indicate your requirements below by checking the appropriate box
Proof Of Insurance $0
Additional Insured Often $0, however the cost will vary with AI type and insurance company
Please note any specific AI requirements:

ADDITIONAL INSURED MUST BE PAID UP FRONT PRIOR TO ISSUANCE (IF APPLICABLE)
(You can find payment-by-fax forms on our web site under the Forms/Documents tab
or click here)

Please complete the following describing the Additional Insured or Proof
of Insurance Holder
To:
Address:
City, State, Zip:
Attention:
Phone:  Fax:
Please complete the following for Additional Insured requests
(not required for Proof of Insurance)
Start Date: (NOTE: If over 30 days past, you will need a no loss letter)
Job Location*:
Street Address:
City, State, Zip:
*If job location is in multiple counties, please state the counties where work will be performed
Job Description:
Is this a residential project? Yes No
What is the expected duration of the job (in days)? Expected total cost?
What is the number of field employees on the job site for the AI (include the owner)?
If this is a commercial project, what is the type of business performed there?
        (i.e. Nail Salon, Law Office, Restaurant, etc
Work Subcontracted Out:
Additional Insured’s relationship to the policyholder: (please check one below)
     General Contracting Owner Landlord Public Entity/Permits
     Prop. Management Retail Supplier Lender Warranty/Referral Firm
     Engineer Architect
Other:
Does the AI maintain primary insurance to cover the exposure risk? Yes No
Check any of the items below that the job involves:
     Tract Homes Condos Townhouses Apartments
     Loft Conversions Work is for National Retailer
What is the job type?
     New Construction Remodel Service/Repair Apartments
Do you have a written contract with the AI? Yes No