COMPLETE THIS FORM TO BE ADDED AS AN ADDITIONAL INSURED

ON AMERICAN DIGITALS LIABILITY POLICY. (Cencom.com, Inc)

A one time $50.00 initialization fee is required, plus a $50.00 annual fee.

* 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 *	<-- CLICK HERE to acknowledge the Onetime $50.00 initialzation fee, plus a $50.00 annual fee charged to your Dealer account to be listed as an additional insured.
I have read and agree to the Privacy Policy *