NAME: _________________________________ Account #: _________________________

REQUEST FOR ADDITIONAL INSURED
Complete the following questionnaire and return to:

American Professional Agency, Inc.
95 Broadway
Amityville, NY  11701

1. Name & Address of proposed Additional Insured:
   
   
   
   
   
2. Nature of proposed Additional Insured's Business:
   
   
   
   
   
3. The Additional Insured is my:
   
   Employer________________________Landlord______________________
   
   Professional Corporation________Other_________________(specify)
   
   
4. The Additional Insured gives me the following form to file with the IRS:
   
   W-2_________________________1099____________________________
   
   Other______________________________________________(specify)
   
   
5. Describe relationship between you and the proposed additional insured:
   
   
   
   
   
6. Are you requesting that the entity named in Question #1 be added
   as an additional insured in order to fulfill a contractual obligation?
   
   [ ..] No [ ..] Yes : If yes, give full particulars:
   
   ________________________________________________________________
   
   Signature of Insured:_____________________________ Date:___________
   
   Signing this form and tendering premium does not bind the applicant or the Company to adding the proposed additional insured to the policy. Please make checks payable and mail to the "American Professional Agency, Inc."

   [ ..] EXECUTIVE RISK INDEMNITY INC
   
   [ ..] DARWIN NATIONAL ASSURANCE COMPANY
   
   [ ..] PLATTE RIVER INSURANCE COMPANY
   
   [ ..] DARWIN SELECT INSURANCE COMPANY