Certificate of Insurance Request

Please complete the following to obtain a certificate of insurance (COI) to submit to a third party vendor/sponsor.

Type of COI requested*
(You may select more than one type of COI if required)
General liability and/or workers’ compensation COI Request
Student Intern COI Request
Auto Liability COI Request
Certificate Holder (entity requesting the COI)
Certificate Holder Organization Name:*

Address*
Street Address Address Line 2 City State ZIP Code

Event or Activity:*
Reason for COI

Event Start Date*
MM slash DD slash YYYY

Event End Date*
MM slash DD slash YYYY

Student Intern COI Request
Student Name*
First Last
Student Email*

College*

Department*

Course Name / Number

Class of...

Sponsor Information
Sponsor Name*
First Last
Sponsor Address*
Street Address Address Line 2 City State ZIP Code

Sponsor Phone
Sponsor Email*

Requester Information
Requester Name*
First Last
Requester Email*