Who can sign the request?

An authorized representative of the insured or the broker should sign. Ensure the signer has written authority from the policyholder or an agent of record to request endorsements.

Is a notarized signature required?

Not generally required for endorsement requests, but some carriers or state-specific situations may ask for notarization; confirm with the insurer or broker.

Can I submit the form electronically?

Yes; electronic submission is widely accepted under ESIGN and UETA for interstate transactions. Confirm insurer portal or broker acceptance and any required consent disclosures.

What if the insurer denies the inclusion?

Carrier denial should include reasons. Review policy exclusions, timing relative to loss, and contract requirements; consider broker escalation or legal review.

How long does processing take?

Processing times vary by carrier and broker workload; submit well before contract deadlines and allow several business days for standard handling.

How should I store completed forms?

Keep signed copies in encrypted document storage with retention aligned to policy life plus applicable statutory retention periods and audit needs.

Electronic Signature
Templates
Insurance
Insurance Inclusion Form

Insurance Inclusion Form

This template is fully customizable. Edit the text, fill out the fields, and send it for signature. Give it a try!

INSURANCE INCLUSION FORM

Use this form to request the inclusion of an additional insured, additional interest, location, or other insured status under an existing insurance policy. Completion and signature by an authorized representative of the named insured constitutes a request and certification that the information provided is true and correct and that the requested inclusion is consistent with any written agreement between the parties.

Applicant / Insured Information

Full legal name of insured Insured address

Date of birth

Primary contact phone

Email address

Policy Details

Insurer / Company name

Policy number

Inclusion effective date

Policy period - start

Policy period - end

Coverage limit per occurrence

Aggregate limit

Deductible

Premium adjustment for inclusion (if known)

Type of Inclusion Requested

Select the nature of the inclusion being requested. Selection does not by itself amend policy language; any change in coverage is effective only upon issuance of an endorsement by the insurer.

Inclusion type (check all that apply) Additional Insured Additional Interest / Loss Payee Location / Property Addition Other (describe below)

Name of party/entity to be included Address of party/entity to be included Relationship to insured / reason for inclusion If Other, describe requested inclusion

Coverage / Limits to Apply to Included Party

Indicate specific coverages and limits that should apply to the included party. Inclusion will be subject to the policy's terms, conditions, exclusions, endorsements and any premium adjustments identified above.

Coverages requested (check all that apply) General Liability Property / Building Coverage Automobile Liability Workers' Compensation Professional / E&O Cyber / Data Breach

Limit to apply to included party

Deductible applicable

Exclusions and Limitations

The inclusion requested does not expand coverage beyond the terms, conditions, limitations and exclusions of the underlying policy. The insurer's obligation to provide coverage to the included party is governed solely by the policy and any subsequently issued endorsement. By signing below, the insured acknowledges and agrees to the following standard exclusions unless otherwise expressly endorsed:

Contractual liability not covered except where required by written contract and endorsed Pollution, contamination and environmental damage exclusion applies unless specifically endorsed War, nuclear hazard and intentional acts exclusions apply Known prior acts or claims are excluded unless disclosed and accepted in writing

Beneficiary / Additional Interest (if applicable)

Provide beneficiary or additional interest details for property, loss payee or mortgagee designation. This section applies when the inclusion requests recognition of financial interest rather than insured status.

Beneficiary or additional interest name

Relationship to insured

Percentage of interest

Documentation Checklist

Attach copies of documents that support this inclusion request. The insurer may require additional documentation prior to issuing an endorsement.

Current Certificate of Insurance Existing endorsements and policy declarations Lease, contract or agreement requiring inclusion Proof of financial interest or loss payee documentation Photos, site plans or descriptions of premises

Declaration and Certification

I hereby request the inclusion described above and certify that the information provided on this form is true, complete and correct to the best of my knowledge. I acknowledge that the requested inclusion will become effective only upon issuance of an endorsement by the insurer and that no change in coverage is effective prior to such endorsement. I authorize the insurer to act on this request and to charge any additional premium due as a result of this inclusion to the insured's policy account.

I further acknowledge that the insurer may rely on this certification and that any false statement or omission material to the acceptance of this request may result in denial of coverage or rescission of the inclusion to the fullest extent permitted by the policy and applicable law.

Additional remarks / special instructions

Acknowledgment

By signing below, the undersigned represents they are an authorized representative of the named insured with authority to request the inclusion and to bind the insured to the statements and authorizations contained herein.

Applicant / Insured (Print Name):

By (Signature):

Date:

What an Insurance Inclusion Form Is

An Insurance Inclusion Form documents the addition of a person, organization, or interest as an insured or additional insured on an existing insurance policy or endorsement. It records the party to be included, the scope of coverage, effective and expiration dates, policy number, and any special conditions needed by a certificate holder, mortgagee, landlord, or contracting party. The form can be used to request an endorsement from the insurer, to evidence coverage for third-party contracts, and to confirm who may claim benefits or make a coverage-related inquiry under the policy.

Why Completing the Insurance Inclusion Form Matters

An accurate inclusion form protects contractual relationships by documenting who is covered, when coverage applies, and any limits or exclusions. It reduces disputes about entitlement to coverage and helps claim handling by creating a clear administrative record tied to the policy.

Who Typically Completes or Receives This Form

The form is completed by policyholders, agents, brokers, or risk managers to add another party to a policy or to provide proof of coverage.

Insurance agents and brokers who coordinate endorsements with carriers and maintain client records.
Risk managers and corporate contracting teams needing proof of coverage for vendors and partners.
Third-party certificate holders such as landlords, lenders, or general contractors requiring evidence of insurance.

Core Components You’ll Find on a Professional Inclusion Form

A complete form combines identifying information, policy details, the exact inclusion requested, and signature authority so the insurer can issue the endorsement without follow-up. Each element should be clear to avoid processing delays.

Insured Details

Name, mailing address, contact phone, and email for the primary policyholder or organization requesting the inclusion.

Additional Insured

Full legal name and address of the party to be added; specify whether the addition is for operations, premises, project, or contractual obligation.

Policy Information

Carrier name, policy number, effective and expiration dates, coverage types (GL, Auto, Workers’ Comp), and limits.

Scope of Inclusion

Precise language describing the extension of coverage (e.g., 'as respects liability arising out of operations performed by the named insured').

Reason for Request

Contract name, job or project, certificate holder requirement, or mortgagee/lender interest prompting the inclusion.

Authorization

Signature, printed name, title, and date from an authorized agent, broker, or policyholder authorized to request endorsements.

Step-by-Step: Completing and Submitting an Inclusion Request

Follow this concise sequence to prepare and route the form so the insurer can process the inclusion efficiently.

01

Gather Documents: Collect policy details, contract clause, and certificate holder information.
02

Complete Form: Enter all required fields, format dates as MM/DD/YYYY, and verify names.
03

Obtain Authorization: Have an authorized representative sign and date the request.
04

Submit to Carrier: Send to the insurer or broker via the carrier’s accepted channel for endorsements.

How to Configure an Online Inclusion Workflow

Configure fields, approvals, and integrations for an online process that routes requests to brokers and insurers automatically.

Field	Configuration
Mandatory Fields	Mark name, policy number, effective date, and scope as required.
Conditional Logic	Show additional fields only when 'Additional Insured' is selected.
Approval Routing	Route to broker then to insurer; include CC to certificate holder.
Integrations	Connect with CRM or document storage (Salesforce, NetSuite, Google Workspace).

Where to Send the Completed Form

Select the correct destination based on whether the endorsement is issued by the carrier or broker and whether a certificate is required.

Primary Insurer: Send to carrier underwriting or endorsements department for action.
Broker / Agent: Submit to your broker when they handle endorsement issuance.
Certificate Holder: Provide the updated certificate or endorsement copy to the requesting third party.
Risk Management: File a copy with internal risk and contract teams for audit trails.

Digital Submission and Technical Requirements

Use formats and delivery methods accepted by insurers and brokers to avoid processing delays.

Accepted Formats: PDF or DOCX with readable text
Authentication: Email link or MFA for signer verification
Storage: Encrypted storage with access controls

Timing Considerations and Typical Deadlines

Certain timing rules influence when to file an inclusion request, particularly around renewal, policy changes, and claim notifications.

Upon Request:

Provide the form whenever a certificate holder requests proof of insured status.

Before Renewal:

Submit changes prior to the policy renewal date to ensure continuous coverage.

Claims-Related:

Request retroactive inclusion immediately if a claim involves the third party.

Contract Deadlines:

Meet contractual insurance deadlines stated in procurement or lease agreements.

Insurer Processing:

Allow carrier processing time; response windows vary by insurer and broker workload.

Common Mistakes to Avoid

Providing inconsistent names or inaccurate policy numbers that prevent carrier verification and delay endorsements.
Failing to specify the exact scope of coverage required by the contract, resulting in incomplete protection.
Submitting requests after the renewal date or after a loss event, which may make retroactive coverage unavailable.
Skipping authorization or using an unauthorized signatory, which can invalidate the endorsement request.

Risks and Consequences of Incorrect or Late Submissions

Coverage Gap: Losses may not be covered for parties not properly added.

Contract Breach: Failure to provide required proof can breach contractual obligations.

Claim Denial: Insurer may deny claims if inclusion was not timely or accurate.

Premium Adjustments: Carrier may reassess premiums or charge endorsements fees.

Regulatory Risk: Industry-specific rules could expose parties to fines or sanctions.

Reputational Harm: Delays or denials can harm vendor or client relationships.

Security and Compliance Features to Protect Form Data

Encryption: TLS 1.2/1.3 in transit; AES-256 at rest

Audit Trail: Timestamps, IP addresses, and action logs

HIPAA Support: HIPAA-compliant workflows available with a BAA

ESIGN / UETA: Compliant with ESIGN and UETA legal standards

Certifications: SOC 2 Type II and ISO 27001 certified

Accessibility: WCAG 2.0 Level AA accessibility support

Frequently Asked Questions about Insurance Inclusion Forms

Answers to common questions about who signs, acceptable formats, timing, and electronic submission to avoid routine processing delays.

Need help? Contact support

Who can sign the request?
An authorized representative of the insured or the broker should sign. Ensure the signer has written authority from the policyholder or an agent of record to request endorsements.
Is a notarized signature required?
Not generally required for endorsement requests, but some carriers or state-specific situations may ask for notarization; confirm with the insurer or broker.
Can I submit the form electronically?
Yes; electronic submission is widely accepted under ESIGN and UETA for interstate transactions. Confirm insurer portal or broker acceptance and any required consent disclosures.
What if the insurer denies the inclusion?
Carrier denial should include reasons. Review policy exclusions, timing relative to loss, and contract requirements; consider broker escalation or legal review.
How long does processing take?
Processing times vary by carrier and broker workload; submit well before contract deadlines and allow several business days for standard handling.
How should I store completed forms?
Keep signed copies in encrypted document storage with retention aligned to policy life plus applicable statutory retention periods and audit needs.

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