ACORD 855 NY (2014/05) released 04-29-2014
ACORD 855 NY (2014/05) - New York Construction Certificate of Liability Insurance Addendum
ACORD 855 NY, New York Construction Certificate of Liability Insurance Addendum, may be used to supplement ACORD 25, Certificate of Liability
Insurance, in the state of New York, to provide more information about the policy's coverage when required by the certificate holder. It is not
intended to answer specific coverage questions, but merely to indicate areas of coverage where the solicitation of more details may be expedient
(e.g., examination of the actual policy forms).
Form Page 1
Section Name
Field Name
Description
IDENTIFICATION SECTION
Agency Customer ID
Enter identifier: The customer's identification number assigned by the producer (e.g., agency or
brokerage).
IDENTIFICATION SECTION
Date
Enter date: The date on which the form is completed. (MM/DD/YYYY)
IDENTIFICATION SECTION
Agency
Enter text: The full name of the producer / agency.
IDENTIFICATION SECTION
Policy Number
Enter identifier: The identifier assigned by the insurer to the policy, or submission, being
referenced exactly as it appears on the policy, including prefix and suffix symbols. If required for
self-insurance, the self-insured license or contract number.
IDENTIFICATION SECTION
Effective Date
Enter date: The effective date of the policy. The date that the terms and conditions of the policy
commence. (MM/DD/YYYY)
IDENTIFICATION SECTION
Named Insured(s)
Enter text: The named insured(s) as it / they will appear on the policy declarations page.
IDENTIFICATION SECTION
Carrier
Enter text: The insurer's full legal company name(s) as found in the file copy of the policy. Use
the actual name of the company within the group to which the policy has been issued. This is
not the insurer's group name or trade name.
IDENTIFICATION SECTION
NAIC Code
Enter code: The identification code assigned to the insurer by the NAIC.
ADDENDUM INFORMATION
Certificate Number
Enter identifier: The producer assigned number for the certificate.
ADDENDUM INFORMATION
Revision Number
Enter number: The producer assigned revision number for the certificate.
ADDENDUM INFORMATION
A. Insurer - Admitted /
Authorized (check box)
Check the box (if applicable): Indicates that this is a group of insurers that is admitted or
authorized in the state of New York.
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ADDENDUM INFORMATION
Excess Line or Free Trade
Zone (check box)
Check the box (if applicable): Indicates that this a group of insurers (known as surplus lines in
other states) that are not authorized in the state of New York, but are included on the stamping
list of approved unauthorized insurers maintained by the Excess Line Association of New York.
The coverage implications are that these insurers are exempt from filing their rate and forms
with the Department of Financial Services. Significant variance in the language of forms and
endorsements should be expected with these policies. In addition, policies written by
unauthorized insurers are not afforded by the insolvency protection of the Property / Casualty
Insurance Security Fund.
Free Trade Zone refers to regulatory exemptions for ''special risks that may be written by
authorized insurers having a special FTZ license. FTZ provisions allow these insurers an
exemption from rate and form filing requirements so they may effectively compete with excess
line insurers in the special risks market. They are authorized insurers, so the Property /
Casualty Insurance Security Fund is applicable to policies written by them.
ADDENDUM INFORMATION
B. General Liability (GL)
Policy Form - ISO / ISO
Modified (check box)
Check the box (if applicable): Indicates that the Insurance Service Office, Inc develops standard
insurance forms for use by its member insurers. The ISO CG 00 01 Commercial General
Liability Coverage Form is often used to insure construction risks. With access to the list of
forms on the declarations, the extent of coverage can be determined from these standard forms,
which are generally available from policyholders and industry representatives. Another benefit
in using standard forms is that the language has undergone years of judicial interpretation,
which gives the determination of coverage more certainty. However, it is not uncommon for
insurers to modify the basic ISO CGL form with language preferred by the insurer.
ADDENDUM INFORMATION
Other (check box)
Check the box (if applicable): Indicates that insurers have filed proprietary forms of their own,
which makes comparisons with standard forms more difficult and language interpretation less
certain.
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ADDENDUM INFORMATION
C. Specific Operations
Excluded or Restricted (GL
Policy) - Location (check
box)
Check the box (if applicable): Indicates that specific operations are excluded or restricted on the
GL policy. While the unendorsed ISO CG 00 01 Commercial General Liability Coverage Form
does not limit its coverage to any specific location, three standard ISO endorsements exist that
can be used to restrict coverage by location:
CG 21 00 Exclusion - All Hazards In Connection With Designated Premises
This endorsement allows the insurer to describe a location of premises where coverage is
excluded. For example it may exclude all work conducted in New York City.
CG 21 34 Exclusion - Designated Work
This endorsement excludes the completed operations liability exposure for work shown in the
schedule, which could be a project or designated work at a specific location. More likely, it
would exclude work of a specific type and/or during a specific time period. Ongoing operations
remain covered.
CG 21 53 Exclusion - Designated Ongoing Operations
This endorsement excludes the ongoing operations liability exposure of a specific type. The
excluded operation also can be specific to a location. Completed operations remain covered.
Nonstandard endorsements may restrict coverage to a specific location eliminating all others.
ADDENDUM INFORMATION
Location
Enter text: The specific description of the location being excluded if applicable or indicate if the
location is for a project or designated work at a specific location.
ADDENDUM INFORMATION
Type of Construction (check
box)
Check the box (if applicable): Indicates that the specific operations are excluded or restricted by
type of construction on a GL policy. However, there is no standard endorsement for this
purpose. While the unendorsed ISO CG 00 01 Commercial General Liability Coverage Form
does not limit its coverage to any specific type of construction, nonstandard endorsements may
designate residential, single-family, apartment, condominium, townhome, track home,
habitational or commercial construction as restricted or excluded.
ADDENDUM INFORMATION
Type of Construction
Enter text: The description of the building's occupancy. As used here, indicates the type of
construction and indicates the location is occupied as either a residential, single family,
apartment, condominium, townhouse, track home, habitational or commercial structure.
ADDENDUM INFORMATION
Building Height (check box)
Check the box (if applicable): Indicates that the specific operations are excluded or restricted by
type of building height on a GL policy. However, there is no standard endorsement for this
purpose. While the unendorsed ISO CG 00 01 Commercial General Liability Coverage Form
does not limit its coverage to any specific building height, nonstandard endorsements may
designate the number of floors / stories that are either covered or excluded.
ADDENDUM INFORMATION
Building Height
Enter number: The number of stories or floors for this building not including any basement.
ADDENDUM INFORMATION
Classifications (check box)
Check the box (if applicable): Indicates that the specific operations are excluded or restricted by
type of classifications on a GL policy. However, there is no standard endorsement for this
purpose. While the unendorsed ISO CG 00 01 Commercial General Liability Coverage Form
does not limit its coverage to any specific risk classification, nonstandard endorsements may
designate specific classifications as either covered or excluded.
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ADDENDUM INFORMATION
Designated Work (check
box)
Check the box (if applicable): Indicates that the specific operations are excluded or restricted by
designated work on a GL policy. While the unendorsed ISO CG 00 01 Commercial General
Liability Coverage Form does not limit its coverage to any specific work designation, three
standard ISO endorsements exist that can be used to restrict coverage by designated work:
CG 21 34 Exclusion - Designated Work
This endorsement excludes the completed operation liability exposure for designated work
shown in the schedule. Ongoing operations remain covered.
CG 21 53 Exclusion - Designated Ongoing Operations
This endorsement excludes the ongoing operations liability exposure of a specific type. The
excluded operation also can be specific to a location. Completed operations remain covered.
CG 21 86 Exclusion - Exterior Insulation and Finish Systems
This endorsement excludes the ongoing operations and products / completed operations liability
exposures that arise from the presence of EIFS-clad exterior work or products.
Nonstandard endorsements may designate specific work or operations as either covered or
excluded.
ADDENDUM INFORMATION
D. Additional Insured
Endorsement (GL Policy) -
CG 20 10 (check box)
Check the box (if applicable): Indicates the CG 20 10 Additional Insured - Owners, Lessees Or
Contractors - Scheduled Person Or Organization endorsement is requested. The current edition
of the endorsement insures as an additional insured in the described person or organization or
ongoing operations of the named insured performed for the additional insured. For example, a
subcontractor's policy could name the general contractor as an additional insured.
ADDENDUM INFORMATION
CG 20 26 (check box)
Check the box (if applicable): Indicates the CG 20 26 Additional Insured - Designated Person Or
Organization endorsement is requested. The current edition of this endorsement insures as an
additional insured the described person or organization for the named insured's 1) performance
of ongoing operations and 2) premises exposures. The covered ongoing operations do not
necessarily have to be performed for the additional insured.
ADDENDUM INFORMATION
CG 20 32 (check box)
Check the box (if applicable): Indicates the CG 20 32 Additional Insured - Engineers, Architects
Or Surveyors Not Engaged By The Named Insured endorsement is requested. The current
edition of this endorsement insures as an additional insured the described engineer, architect or
surveyor for the named insured's performance of ongoing operations. This coverage applies
when the named insured is obligated by contract to add the engineer, architect or surveyor on
the policy, but has not actually engaged their work. The CG 20 07 would be used when the
engineer, architect or surveyor is engaged by the named insured to do the work.
ADDENDUM INFORMATION
CG 20 33 (check box)
Check the box (if applicable): Indicates the CG 20 33 Additional Insured - Owners, Lessees Or
Contractors - Automatic Status When Required In Construction Agreement With You
endorsement is requested. The current edition of this endorsement insures as an additional
insured for any person or organization for ongoing operations of the named insured performed
for the additional insured. However, this automatic coverage requires a written agreement
obligating the named insured to add the additional insured on the policy.
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ADDENDUM INFORMATION
CG 20 37 (check box)
Check the box (if applicable): Indicates the CG 20 38 Additional Insured - Owners, Lessees Or
Contractors - Completed Operations endorsement is requested. The current edition of this
endorsement insures as an additional insured the described person or organization for
completed operations, resulting from work (described by location) the named insured
performed for the additional insured. This endorsement can restore the completed operations
coverage that previously was included in the 1985 edition of the CG 20 10 endorsement.
ADDENDUM INFORMATION
CG 20 38 (check box)
Check the box (if applicable): Indicates the CG 20 38 Additional Insured - Owners, Lessees Or
Contractors - Automatic Status For Other Parties When Required In Written Construction
Agreement endorsement is requested. The current edition of the endorsement insures as an
additional insured any person or organization for ongoing operations of the named insured
performed for the additional insured. Unlike the CG 20 33 endorsement, this endorsement also
provides additional insured status to all parties the named insured agrees in writing to insure.
ADDENDUM INFORMATION
Other (check box)
Check the box (if applicable): Indicates an endorsement other than those listed has been
selected.
ADDENDUM INFORMATION
Endorsement Number
Enter identifier: The number of the other Additional Insured endorsement.
ADDENDUM INFORMATION
Endorsement Title
Enter text: The full title name of the other Additional Insured endorsement.
ADDENDUM INFORMATION
E. According to the terms of
this GL policy, the
additional insured has
primary and
noncontributory coverage -
Yes (check box)
Check the box (if applicable): Indicates the additional insured on the policy has primary and
noncontributory coverage. The typical general liability policy (for example, the ISO CG 00 01
Commercial General Liability Coverage Form) provides primary coverage to insureds, except
when the coverage is specifically stated as excess in the Other Insurance provision of the policy.
However, this primary coverage will contribute (i.e., share) with any other coverage available to
the insured on the same primary basis. For example, since the general contractor typically has
primary general liability coverage as a named insured, that policy would share the loss with the
policy providing the general contractor coverage as an additional insured.
ISO provided a solution in 1996 to prevent contribution between the two policies by adding
language to the Other Insurance provision that would make the general contractor's policy
excess over the policy that insures the general contractor as an additional insured.
Nevertheless since the subcontractor's producer is not privy to the policy terms on the general
contractor's policy, it would be reckless of the producer to warrant that coverage would NOT be
shared (i.e., noncontributory).
Consequently, ISO provided an alternate solution with its optional Primary and Noncontributory -
Other Insurance Condition endorsement (CG 20 01). Insurers may adopt this endorsement
filing in New York effective April 1, 2013. The endorsement states that the (subcontractor's)
insurer will not seek contribution from the policy of the additional insured (general contractor).
However the endorsement requires that there be an underlying written contract or agreement
stating that the (subcontractor's) coverage for the additional insured (general contractor) must
be primary and noncontributory. When the endorsement is added to the policy, the certificate
unequivocally can state that coverage is primary and noncontributory.
There have been non standard endorsements in use prior to ISO's introduction of the CG 20 01
endorsement so watch for these forms, observing the variance in language.
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ADDENDUM INFORMATION
No and (check box)
Check the box (if applicable): According to the terms of the GL policy, indicates the additional
insured on the policy does not have primary and noncontributory coverage.
ADDENDUM INFORMATION
No other option available
with this insurer (check box)
Check the box (if applicable): According to the terms of the GL policy, indicates the additional
insured on the policy does not have primary and noncontributory coverage and that no other
option is available with this insurer.
ADDENDUM INFORMATION
F. Additional insured will
receive advance notice if
insurer cancels (GL policy) -
Yes (check box)
Check the box (if applicable): Indicates the additional insured will receive advance notice if the
insurer cancels the GL policy. There is no standard endorsement for this purpose. Some
insurers will provide notice using nonstandard endorsements, but this is rare. Even if such
endorsement is available, it may not provide notice resulting from nonpayment of premium or
cancellation by the policyholder.
ADDENDUM INFORMATION
No and (check box)
Check the box (if applicable): Indicates the additional insured will not receive advance notice if
the insurer cancels the GL policy.
ADDENDUM INFORMATION
No other option available
with this insurer (check box)
Check the box (if applicable): Indicates that the additional insured will not receive advanced
notice if the insured cancels the GL policy and no other option is available from this insurer.
ADDENDUM INFORMATION
G. Blanket contractual
liability located in the
insured contract definition
(Section V, Number 9, Item f.
in the ISO CGL policy) is
removed or restricted - Yes
(check box)
Check the box (if applicable): Indicates the blanket contractual liability located in the insured
contract definition (Section V, Number 9, Item f. in the ISO CGL policy) is removed or
restricted.
Item f. of the insured contract definition in the ISO CG 00 01 Commercial General Liability
Coverage Form is a good example of what is meant by blanket contractual liability. It reads as
follows:
That part of any other contract or agreement pertaining to your business (including an
indemnification of a municipality in connection with work performed for a municipality) under
which you assume the tort liability of another party to pay for bodily injury or property damage
to a third person or organization. Tort liability means a liability that would be imposed by law in
the absence of any contract or agreement.
This is an important policy provision that will, for example, insure a subcontractors
indemnification of a general contractor. ISO has a standard CG 21 39 Contractual Liability
Limitation endorsement that can be used for the removal of Item f. in the insured contract
definition. If removed, there will be no coverage to back up the indemnification agreement.
While the ISO CG 24 26 Amendment Of Insured Contract Definition endorsement may routinely
be attached to a policy in order to exclude coverage for the sole negligence of an indemnitee, it
has no relevance in New York where General Obligations Law Section 5-322.1 makes such
indemnification unenforceable.
ADDENDUM INFORMATION
No other optional available
with this insurer (check box)
Check the box (if applicable): Indicates that the blanket contractual liability located in the
insured contract definition (Section V, Number 9, Item f. in the ISO CGL policy) is removed or
restricted and no other option is available with this insurer.
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ADDENDUM INFORMATION
No changes made (check
box)
Check the box (if applicable): Indicates that no changes are made to the policy regarding
blanket contractual liability located in the insured contract definition (Section V, Number 9, Item
f.) in the ISO CG 00 01.
ADDENDUM INFORMATION
H. Insured contract
exception to the employers
liability exclusion is
removed or modified (GL
policy) - Yes and (check
box)
Check the box (if applicable): Indicates the insured contract exception to the employer's liability
exclusion is removed or modified (GL policy).
While suits by injured employees against the named insured [employer] are excluded (WC is the
exclusive remedy), the exception in the ISO CG 00 01 Commercial General Liability Coverage
Form affords insured contract coverage when the injured employee, for example, sues the
general contractor and the named insured [employer] has indemnified the general contractor for
such suits.
While there is no standard endorsement that removes or modifies this exception to the
employers liability exclusion, some insurers have made use of policy wording or nonstandard
endorsements to eliminate this coverage.
ADDENDUM INFORMATION
No other option is available
with this insurer (check box)
Check the box (if applicable): Indicates the insured contract exception to the employer's liability
exclusion is removed or modified on the GL policy and no other option is available with this
insurer.
ADDENDUM INFORMATION
No changes made (check
box)
Check the box (if applicable): Indicates that no changes were made to the insured contract
exception to the employer's liability exclusion on the ISO CG 00 01.
ADDENDUM INFORMATION
I. GL policy (including
endorsements) does not
cover the additional insured
for claims involving injury to
employees of the named
insured or subcontractors
(not workers'
compensation) - Yes and
(check box)
Check the box (if applicable): Indicates the GL policy (including endorsements) does not cover
the additional insured for claims involving injury to employees of the named insured or
subcontractors (not workers' compensation).
The ISO CG 00 01 Commercial General Liability Coverage Form and ISO Additional Insured
endorsements do not exclude suits by an injured employee against an insured who is not the
employer. While there is no standard endorsement that eliminates coverage for an additional
insured when suits are made by employees of the named insured, insurers have used policy
wording or nonstandard endorsements for this purpose.
For example, simply changing the wording of the employers liability exclusion from employees
of the insured to employees of any insured will preclude coverage for all insureds, whether the
injured person is employed by that insured or not. When a general contractor is an additional
insured, the modified exclusion prevents the subcontractors policy from insuring the general
contractor for injuries to employees of the subcontractor.
ADDENDUM INFORMATION
No other option is available
with this insurer (check box)
Check the box (if applicable): Indicates that the GL policy (including endorsements) does not
cover the additional insured for claims involving injury to employees of the named insured or
subcontractors (not workers' compensation) and no other option is available with this insurer.
ADDENDUM INFORMATION
No changes made (check
box)
Check the box (if applicable): Indicates that no changes were made to the GL policy (including
endorsements) regarding additional insured coverage for claims involving injury to employees of
the named insured or subcontractors.
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Form Page 2
Section Name
Field Name
Description
IDENTIFICATION SECTION
Agency Customer ID
Enter identifier: The customer's identification number assigned by the producer (e.g., agency or
brokerage).
ADDENDUM INFORMATION
(continued)
J. Earth movement,
excavation or explosion /
collapse / underground
property damage is
excluded or restricted (GL
policy) - Yes and (check
box)
Check the box (if applicable): Indicates that earth movement, excavation or explosion / collapse
/ underground property damage is excluded or restricted on the GL policy.
While the unendorsed ISO CG 00 01 Commercial General Liability Coverage Form has no
restriction applicable to earth movement, excavation, explosion (blasting), collapse or
underground property hazards, two standard ISO endorsements exist that can be used to
modify this coverage:
CG 21 42 Exclusion Explosion, Collapse And Underground Property Damage Hazard
(Specified Operations)
This endorsement allows the insurer to exclude ongoing operations for specific hazards (i.e.,
collapse hazard; explosion hazard; and/or underground property damage hazard) by
location and/or operations designated on the endorsement.
CG 21 43 Exclusion Explosion, Collapse And Underground Property Damage Hazard
(Specified Operations Excepted)
This endorsement allows the insurer to exclude ongoing operations for all three specific hazards
(i.e., collapse hazard; explosion hazard; and underground property damage hazard), except
the specific hazard(s) included in operations and/or locations designated on the endorsement.
Nonstandard endorsements may reference excluded hazards, such as, earth movement,
subsidence or excavation.
ADDENDUM INFORMATION
(continued)
No other option is available
with this insurer (check box)
Check the box (if applicable): Indicates that earth movement, excavation or explosion / collapse
/ underground property damage is excluded or restricted on a GL policy and no other option is
available with this insurer.
ADDENDUM INFORMATION
(continued)
No changes made (check
box)
Check the box (if applicable): Indicates that no changes have been made to the GL policy
regarding earth movement, excavation or explosion / collapse or underground property damage.
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ADDENDUM INFORMATION
(continued)
K. Insured vs. insured suits
(cross liability in the ISO
CGL policy) are excluded or
restricted (other than named
insured vs. named insured) -
Yes and (check box)
Check the box (if applicable): Indicates that insured vs. insured suits (cross liability in the ISO
CGL policy) are excluded or restricted (other than named insured vs. named insured).
General liability policies typically cover more than one person or entity, consisting of named
insureds, automatically defined insureds and additional insureds. Cross liability refers to one
insureds suit against another insured.
Coverage for cross liability suits among insureds can be impacted by several provisions located
in different parts of the policy. The ISO CG 00 01 Commercial General Liability Coverage Form
includes the following condition that opens the coverage door to cross liability suits between
insureds:
7. Separation Of Insureds
Except with respect to the Limits of Insurance, and any rights or duties specifically assigned in
this Coverage Part to the First Named Insured, this insurance applies:
a. As if each Named Insured were the only Named Insured; and
b. Separately to each insured against whom claim is made or suit is brought.
Subject to other policy provisions, it is here we find the policy is applied so every insured enjoys
the same coverage it would have had if a separate policy had been issued for that insured
(except with respect to the limits). If there is no other restrictive wording, an additional insured
would be covered for a suit by an employee of the named insured (who is a defined insured in
the policy).
While there is no standard endorsement to remove coverage for an additional insured sued by
an employee of the named insured, some insurers have made use of nonstandard
endorsements to restrict cross liability suits.
ADDENDUM INFORMATION
(continued)
No other option is available
with this insurer (check box)
Check the box (if applicable): Indicates that insured vs. insured suits (cross liability in the ISO
CGL Policy) are excluded or restricted (other than named insured vs. named insured) and no
other option is available with this insurer.
ADDENDUM INFORMATION
(continued)
No changes made (check
box)
Check the box (if applicable): Indicates that no changes have been made to the ISO CGL policy
regarding insured vs. insured suits.
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ADDENDUM INFORMATION
(continued)
L. Property damage to work
performed by
subcontractors (exception
to the damage to your
work exclusion in the ISO
CGL policy) is excluded or
restricted - Yes and (check
box)
Check the box (if applicable): Indicates that property damage to work performed by
subcontractors (exception to the damage to your work exclusion in the ISO CGL policy) is
excluded or restricted.
The following exception to the Damage To Your Work exclusion appears in the ISO CG 00 01
Commercial General Liability Coverage Form:
This exclusion does not apply if the damaged work or the work out of which the damage arises
was performed on your behalf by a subcontractor.
Because of this exception, the exclusion for property damage arising from completed operations
applies only to work performed by the named insured, and when such work results in the
property damage. Two standard ISO endorsements exist that can be used to modify this
coverage:
CG 22 94 Exclusion Damage To Work Performed By Subcontractors On Your Behalf
This endorsement removes the exception to the Damage To Your Work exclusion, eliminating
coverage for the entire work, whether performed by the named insured or not.
CG 22 95 Exclusion Damage To Work Performed By Subcontractors On Your Behalf
Designated Sites Or Operations
As the title of this endorsement suggests, it allows underwriting flexibility by targeting the
removal of the exception to designated sites or operations.
Also, note that coverage is excluded in the Damage To Property exclusion for property
damaged while being worked on. Some of this exposure can be insured with a Builders Risk
policy.
ADDENDUM INFORMATION
(continued)
No other option is available
with this insurer (check box)
Check the box (if applicable): Indicates that property damage to work performed by
subcontractors (exception to the damage to your work exclusion on the ISO CGL policy) is
excluded or restricted and no other option is available with this insurer.
ADDENDUM INFORMATION
(continued)
No changes made (check
box)
Check the box (if applicable): Indicates that no changes have been made to the ISO CGL policy
regarding property damage to work performed by subcontractors.
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ADDENDUM INFORMATION
(continued)
M. Excess / umbrella policy
is primary and
non-contributory for
additional insureds - Yes by
specific policy provision
(check box)
Check the box (if applicable): Indicates the excess / umbrella policy is primary and
noncontributory for additional insureds by specific policy provision.
True follow form excess / umbrella policies are extremely rare, so care should be taken to
examine the provisions of these policies.
The issue of primary and noncontributory coverage takes on a more complex dimension with
regard to excess / umbrella policies because of the additional insureds access to multiple
policies at different levels of priority.
Vertical Exhaustion establishes coverage priority for the additional insured in such a way as to
require the exhaustion of primary and excess policies purchased by the [downstream]
subcontractor before any policies purchased by the [upstream] general contractor respond with
payment.
Horizontal Exhaustion establishes coverage priority for the additional insured in such a way as
to require the exhaustion of all primary policies available to the [upstream] general contractor
before the excess policy purchased by the [downstream] subcontractor responds with payment.
New York courts do not use the actual terms vertical or horizontal exhaustion, but refer to
these issues as priority of coverage and rely on the Other Insurance clauses contained in
policies to resolve priority issues. Therefore, close examination of these clauses is essential.
ADDENDUM INFORMATION
(continued)
Yes by endorsement (check
box)
Check the box (if applicable): Indicates that the excess / umbrella policy is primary and
noncontributory for additional insureds by endorsement.
ADDENDUM INFORMATION
(continued)
No and (check box)
Check the box (if applicable): Indicates that the excess / umbrella policy is not primary and
noncontributory for additional insureds.
ADDENDUM INFORMATION
(continued)
No other option is available
with this insurer (check box)
Check the box (if applicable): Indicates that the excess / umbrella policy is not primary and
noncontributory for additional insureds and no other option is available with this insurer.
SIGNATURE
Authorized Representative
Signature
Sign here: Accommodates the signature of the authorized representative (e.g., producer, agent,
broker, etc.) of the company(ies) listed on the document. This is required in most states.
SIGNATURE
Date
Enter date: The date the producer signed the form.
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