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 AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific 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 AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code
• Sponsor Phone
• Sponsor Email*

• Requester Information

• Requester Name*
  First Last
• Requester Email*