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*

Certificate Holder (entity requesting the COI)