Certificate of Insurance Request Form

If you are required to provide a Certificate of Insurance to the vendor, contractor, or other entity for any reason, please fill out the following online form:

First Name *

Last Name *

Department

Email *

Phone Number *

Fax Number

Name of Certificate Holder (i.e. Entity requesting the certificate) *

Address of Certificate Holder *

Description of Activity: (This includes events, activities, research projects, leased and rented property, and various contracts.) For events, activities, and performance contracts include the date(s), time(s), and location of the event or activity. For leased and rented property, i.e. computer equipment, includes a description and the dollar value of the property. (It is not necessary to include the value of leased or rented vehicles or the value of buildings when renting space.) *

Type of Certificate of Insurance Requested: *

Auto

Property

General Liability

Professional Liability

Worker's Compensation

Comment Section

Please attach a copy of the contract or sections relating to insurance, indemnification and/or hold harmless agreement with this form.

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Name

Please note, Additional Insured status on a Certificate of Insurance CANNOT be granted without a copy of signed contract requesting same received in this office.