ADDITIONAL INSURED LISTING CERTIFICATE

To obtain this as your FREE BENIFIT SERVICE, Please complete the form and a certificate will be sent to you.

Questions? Call us at 1-800-825-5911

* Required fields
Name *
E-mail Address *
WHO IS COMPLETING THIS FORM? *
WHAT IS THE BEST CONTACT PHONE NUMBER FOR YOU? *
YOUR DEALER I.D. *
YOUR COMPANY NAME *
LEGAL NAME OF YOUR COMPANY *
YOUR BUSINESS ADDRESS, INCLUDE CITY, ST. & ZIP *
FREE BENIFIT TERMS *	I AM AWARE THAT THE LISTINGS ARE PART OF THE FREE BENIFIT PROGRAM WITH AMERICAN DIGITAL AND IS FREE IF I SELECT ONE FREE BASIC SERVICE ONLY. IF MY DEALER ACCOUNT ALREADY HAS A FREE BENIFIT SERVICE, I AGREE TO PAY FULL PRICE FOR THE ADDITIONAL SERVICES AND WILL DO SO AS IF THIS BENIFIT IS A PART OF MY DEALER AGREEMENT WITH AMERICAN DIGITAL.
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