Certificate of insurance – request form

* required Indicates a field that must be filled.

University contact information

First name:*

Last name:*

Title and department:*

Contact email:*

Phone:*

Certificate holder contact information

Organization name:*

Street address 1:*

Street address 2:

City:*

Province/State:*

Postal code:*

Country:*

Contact first name:

Contact last name:

Contact title:

Contact phone number:

Contact fax number:

Contact email address:

Describe the nature of operations for this certificate

Specific activity:*

Date(s) of activity:*

Who is performing this activity?*

Location of activity

Limit(s) of insurance required

Do you require proof of General Liability insurance?

Yes No

General Liability $:

Additional Insured

Yes No

Do you require proof of Errors & Omissions insurance?

Yes No

Errors & Omissions $:

Required date:

Special instructions:

Once you have clicked on the Submit Form button your request will be sent directly to Abby Egeh, Risk & Insurance Analyst, for processing. Thank you.