COMPLETE THIS FORM TO BE ADDED AS AN ADDITIONAL INSURED

ON AMERICAN DIGITALS LIABILITY POLICY.

A $100.00 ANNUAL FEE WILL APPLY.

* Required fields
Name *
E-mail Address *
YOUR DEALER I.D. *
PROMOTIONAL CODE
ADDRESS LINE #1 *
ADDRESS LINE #2
CITY *
STATE *
ZIP CODE *
NAME OF YOUR OWN INSURANCE CARRIER *
WHAT ARE THE EXISTING LIMITS OF YOUR LIABILITY POLICY? *
SPECAIL COMMENTS REGARDING YOUR INSURANCE POLICY
TERMS OF ADDITIONAL INSURED PROGRAM *


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