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Additional Insured Request

Omni Insurance Additional Insured Form:

Please complete this form and provide all information requested in this section.

Additional Insured Request

Chapter

Your Full Name

Job Title

Email

This is for:

Event - Additionally Insured

Insurance Policy - School

Insurance Policy - Other

Event Type

Athletic

Social

Community Service

Recruitment

Band/Concert

Philanthropy (Fundraising)

Food/Dinner/Formal

Other

Will alcohol be present at this event?

Yes

No

Name of Additional Insured

Address

City

State

Zip Code

Phone

Additional Email(s)

Comments

Thank you for contacting us.

We will get back to you as soon as possible.

Gerard J Colistra, President

Omni Insurance Services LLC

12 Mohawk Place

PO Box 474

Amsterdam, New York 12010

gcolistra@omniinsuranceservicesllc.com

518-448-3352 cell

1-833-261-6100 office toll free

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Fraternity Insurance Service

833-261-6100

12 Mohawk Place

PO Box 474

Amsterdam, NY 12010

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Additional Insured Request﻿

Omni Insurance Additional Insured Form: