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Additional Insured Supplement Application.

*Applicant/Insured:
*Address:
Producer:
*Email:
*Policy Number:
Term:
*Phone:
Fax:
*Additional Insured:
*Additional InsuredAddress:
 
The following questions MUST be answered before we consider adding an additional insured to the policy.
*Explain the relationship between the named insured and the additional insured:
*Are there any out of state operations performed by the named insured:
Yes No
*Length of Job:
*Description/Nature of Job (Below):
 
Residential
New Tract Housing
New Condos/Townhomes
Custom Home
Apartments
Other - Details:
Commercial
Industrial/Manufacturing
Mercantile
Office/Institutional
Motel/Hotel
Other - Details:
Any person, who knowingly and with intent to defraud any insurance company or any other person, files an application for insurance containing false information, or conceals for the purpose of misleading, information concerning any fact material thereto, commits a fraudulent insurance act, which is a crime. This application does not bind any of the parties to complete the insurance transaction.