Miscellaneous COI Revision Form

MISCELLANEOUS COI REVISION FORM

Parties and Contact Information

WHEREAS — Recitals

WHEREAS, the Requesting Party identified above is the holder of or otherwise entitled to rely upon a Certificate of Insurance issued in connection with policy number ;

WHEREAS, the Requesting Party requests revisions to the Certificate of Insurance (COI) to reflect changes in certificate holder, additional insured status, limits of liability, waiver of subrogation, or other endorsements as described in this form; and

WHEREAS, the Insurance Carrier or its authorized Broker (collectively "Carrier") is willing to process and, subject to underwriting approval, issue endorsements and a revised COI upon receipt of required documentation and payment as provided below.

Policy and Certificate Details

Revision Requested

Please indicate the revision(s) requested and provide supporting detail. Revisions will be processed only to the extent permitted by the policy terms and underwriting approval.

Scope of Work

Describe the contractual work, services, or relationship giving rise to the certificate requirement. This description will be reflected on the revised COI where permitted by policy terms.

Payment Terms for Revision Processing

The Requesting Party agrees to pay applicable fees for processing endorsements and issuing a revised Certificate of Insurance as set forth below.

Late payments shall accrue interest at the lesser of the rate set forth below or the maximum lawful rate.

Term and Termination

Either party may terminate this COI Revision Agreement for material breach if the breaching party fails to cure within the notice period set forth below. Termination does not relieve the Requesting Party of payment obligations for services performed or fees due prior to termination.

Confidentiality

Each party will keep confidential all non-public information disclosed in connection with this form and any supporting documents, including underwriting and premium information ("Confidential Information"). Confidential Information will not be disclosed except to the extent required by law or to affiliates, reinsurers, auditors, or legal counsel who have agreed to confidentiality obligations. Confidentiality obligations survive for three (3) years following termination of this Agreement.

Insurance Endorsement and Effectiveness

Any requested revision shall be effective only upon issuance of a formal endorsement by the carrier and the delivery of a revised Certificate of Insurance. Neither the Carrier nor Broker makes any representation that requested endorsements will be accepted by underwriters; underwriting approval is required for coverage changes.

Representations, Warranties and Indemnity

The Requesting Party represents that the information provided in this form is true, complete and accurate to the best of its knowledge and agrees to indemnify and hold harmless the Carrier and Broker from claims, liabilities, costs and expenses arising from materially false or misleading information provided in connection with this revision request.

Governing Law

This Agreement and any dispute arising out of or relating to it shall be governed by the substantive laws of the state of , without regard to its conflicts of law principles.

Entire Agreement

This form, together with any attachments and required endorsements issued by the Carrier, constitutes the entire agreement between the parties with respect to the subject matter herein and supersedes all prior oral or written promises, representations or agreements concerning revision of the Certificate of Insurance.

Notices

All notices required under this Agreement must be in writing and delivered to the contact information set forth above by hand, nationally recognized overnight courier, or certified mail, return receipt requested.

Acknowledgment

By signing below, the authorized representatives of the parties acknowledge and agree to the terms of this COI Revision Form and certify that they have authority to bind their respective organizations.

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