Additional Insured Request Form Use this form to add additional insureds for $35 each.   Personal Information Date: Named Insured (First Last): Company Name (if any): Address: City: State, ZIP Code: Email: Phone: Fax:   Policy Information Policy # Premium Limit: Policy Term:   New Information   Number of ADDITIONAL INSUREDS 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 First 10 FREE! $35 each thereafter. (Additional Insured Includes: Landlords, Clubs, and Recreational Dept.)