AGENCY CUSTOMER ID:
ADDITIONAL INTEREST (Not all fields apply to all scenarios - provide only the necessary data)
EFFECTIVE DATE NAMED INSURED(S)POLICY NUMBER
NAIC CODE
CARRIER
AGENCY
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ACORD 45 (2009/04) © 1993-2009 ACORD CORPORATION. All rights reserved.
E-MAIL ADDRESS:REASON FOR INTEREST:
OWNER
LEASEBACK
WARRANTY
BREACH OF
TRUSTEE
REGISTRANT
FAX (A/C, No):PHONE (A/C, No, Ext):LIEN AMOUNT:
INTEREST END DATE:
ITEM:
CLASS:
AIRPORT: AIRCRAFT:CO-OWNER OWNER
SEND BILLPOLICY
EVIDENCE:
AS LESSOR
INSURED
ITEM DESCRIPTION
INTEREST RANK:NAME AND ADDRESS
REFERENCE / LOAN #:
CERTIFICATE
INTEREST IN ITEM NUMBER
ADDITIONAL
LOSS PAYEE
MORTGAGEE
LIENHOLDER
EMPLOYEE
LOCATION: BUILDING:
VEHICLE: BOAT:
ITEM
E-MAIL ADDRESS:REASON FOR INTEREST:
OWNER
LEASEBACK
WARRANTY
BREACH OF
TRUSTEE
REGISTRANT
FAX (A/C, No):PHONE (A/C, No, Ext):LIEN AMOUNT:
INTEREST END DATE:
ITEM:
CLASS:
AIRPORT: AIRCRAFT:CO-OWNER OWNER
SEND BILLPOLICY
EVIDENCE:
AS LESSOR
INSURED
ITEM DESCRIPTION
INTEREST RANK:NAME AND ADDRESS
REFERENCE / LOAN #:
CERTIFICATE
INTEREST IN ITEM NUMBER
ADDITIONAL
LOSS PAYEE
MORTGAGEE
LIENHOLDER
EMPLOYEE
LOCATION: BUILDING:
VEHICLE: BOAT:
ITEM
E-MAIL ADDRESS:REASON FOR INTEREST:
OWNER
LEASEBACK
WARRANTY
BREACH OF
TRUSTEE
REGISTRANT
FAX (A/C, No):PHONE (A/C, No, Ext):LIEN AMOUNT:
INTEREST END DATE:
ITEM:
CLASS:
AIRPORT: AIRCRAFT:CO-OWNER OWNER
SEND BILLPOLICY
EVIDENCE:
AS LESSOR
INSURED
ITEM DESCRIPTION
INTEREST RANK:NAME AND ADDRESS
REFERENCE / LOAN #:
CERTIFICATE
INTEREST IN ITEM NUMBER
ADDITIONAL
LOSS PAYEE
MORTGAGEE
LIENHOLDER
EMPLOYEE
LOCATION: BUILDING:
VEHICLE: BOAT:
ITEM
E-MAIL ADDRESS:REASON FOR INTEREST:
OWNER
LEASEBACK
WARRANTY
BREACH OF
TRUSTEE
REGISTRANT
FAX (A/C, No):PHONE (A/C, No, Ext):LIEN AMOUNT:
INTEREST END DATE:
ITEM:
CLASS:
AIRPORT: AIRCRAFT:CO-OWNER OWNER
SEND BILLPOLICY
EVIDENCE:
AS LESSOR
INSURED
ITEM DESCRIPTION
INTEREST RANK:NAME AND ADDRESS
REFERENCE / LOAN #:
CERTIFICATE
INTEREST IN ITEM NUMBER
ADDITIONAL
LOSS PAYEE
MORTGAGEE
LIENHOLDER
EMPLOYEE
LOCATION: BUILDING:
VEHICLE: BOAT:
ITEM
E-MAIL ADDRESS:REASON FOR INTEREST:
OWNER
LEASEBACK
WARRANTY
BREACH OF
TRUSTEE
REGISTRANT
FAX (A/C, No):PHONE (A/C, No, Ext):LIEN AMOUNT:
INTEREST END DATE:
ITEM:
CLASS:
AIRPORT: AIRCRAFT:CO-OWNER OWNER
SEND BILLPOLICY
EVIDENCE:
AS LESSOR
INSURED
ITEM DESCRIPTION
INTEREST RANK:NAME AND ADDRESS
REFERENCE / LOAN #:
CERTIFICATE
INTEREST IN ITEM NUMBER
ADDITIONAL
LOSS PAYEE
MORTGAGEE
LIENHOLDER
EMPLOYEE
LOCATION: BUILDING:
VEHICLE: BOAT:
ITEM
ADDITIONAL INTEREST SCHEDULE
DATE (MM/DD/YYYY)