Written request to add a third party as an additional insured on one or more existing insurance policies, specifying the policy numbers, coverage lines, endorsement form, and required effective date.
The Additional Insured Endorsement Request is a ready-to-use insurance & risk template you can send for signature in minutes. It is written for 1 signer (policyholder) and, by default, expires 14 days after it is sent if left unsigned. It covers additional insured, endorsement, cg 20 10, cg 20 37, liability, insurance endorsement. Like every Abundera Sign template it is a convenience draft structured for ESIGN Act and UETA compliance, not a substitute for legal advice. Each signed copy is sealed with PAdES-LTA digital signatures, dual RFC 3161 timestamps, and a tamper-evident evidence package in WORM storage.
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# Additional Insured Endorsement Request **Request Date:** ___________ --- ## 1. Policyholder Information **Named Insured (as it appears on the policy):** ___________ **Named Insured Mailing Address:** ___________ **Named Insured Contact Name:** ___________ **Named Insured Contact Email:** ___________ **Named Insured Contact Phone:** ___________ --- ## 2. Insurance Agency / Broker **Agency / Brokerage Name:** ___________ **Agent / Broker Name:** ___________ **Agent / Broker Email:** ___________ **Agent / Broker Phone:** ___________ --- ## 3. Party to Be Added as Additional Insured **Additional Insured Name (legal entity or individual):** ___________ **Additional Insured Address:** ___________ **Relationship of Additional Insured to Named Insured:** ___________