Form U-111 I - Request For Inclusion Of Additional Interest printable pdf download

Form U-111 I - Request For Inclusion Of Additional Interest

REQUEST FOR INCLUSION OF ADDITIONAL INTEREST

NEW YORK STATE INSURANCE FUND, Underwriting Department

199 CHURCH STREET

NEW YORK, NY 10007-1100

Date

We, the undersigned, hereby request that the entity named below be included in the coverage of

POLICY NO.

, as of 12:01 A.M.

Name of entity to be included

Mailing address

Locations to be covered

R.B. File No:

The nature of the ownership and control of the above mentioned entity, and the entity now insured under the Policy is as follows:

PRESENT INTEREST

ADDITIONAL INTEREST

1. Name of Entity

1b. F.E.I.N.

2. Individual, Partnership, Corporation,

Unincorporated Association or Fiduciary

3. Ownership

(a) If not a corporation or a partnership, list

names of owners and their respective

percentages of ownership.

(b) If a partnership, list the full name of

each general partner and his

participation in the profits of the

partnership.

owners of 5% or more of the voting

stock and the number of shares owned

by each.

4. Total number of shares of voting stock of

corporation issued

In consideration of the inclusion of the additional entity named above under the coverage of the Policy, we the undersigned jointly and severally do hereby assume full liability

and responsibility for any and all premiums that may become due THE STATE INSURANCE FUND for coverage extended to either or both the entity now covered and the

additional entity to be covered by the Policy from its inception to cancellation date.

(PRINT)

TRADE NAME OF PRESENT ASSURED

TRADE NAME OF ADDITIONAL INTEREST

(SIGNED BY)

OWNER OR OFFICER, IF A CORPORATION

U-111 I

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