Rental Vehicle Certificate Insurance Request

Requires 24 hours notice to obtain insurance certificates

Your Name*
First Last
Email*
Phone*
Department / Unit*
Project number to be billed*
Rental Coverage Effective Date*
MM slash DD slash YYYY
Rental Coverage End Date*
MM slash DD slash YYYY

If rental is 6 months or more, you will be billed for the entire policy year
Garaged Address*
Street Address Address Line 2 City State ZIP Code
Vehicle Information:
If the Rental Company does not know the exact vehicle that will be leased, obtain the detailed information on any comparable vehicle and the certificate will read coverage for “any substitute vehicle”
This information is:*
- the actual vehicle I am renting
- a comparable vehicle to the one I will be renting
Make-Model*
Year*
Serial / VIN #*
Plate Number*
Replacement Value*
Rental Company Contact Information:
Rental Company*
Contact Name
First Last
Address*
Street Address Address Line 2 City State ZIP Code
Phone*
PLEASE NOTE:
- If rental is 6 months or more, you will be billed for the entire policy year.
- The following physical damage coverage is subject to comprehensive $100.00 deductible and collision $500.00 deductible for vehicles valued under $75,000.00. Higher deductibles apply if vehicle is valued more than $75,000.00.
- There will be an insurance premium charge to your department for the rental, if the rental is over 30 days, or if the vehicle replacement value is over $40,000 for private passenger, and over $60,000 for a truck or if the gross vehicle weight (gvw) is over 10,000 pounds. Any premium charge will be billed at renewal in July.
Important:
- When picking up rental vehicles, Inspect the vehicle for prior damage and notify rental company.
- When returning the vehicle, conduct a full inspection with rental personnel to identify any potential damage
Contact IRM or call (919) 515-6135 with any questions.
Name
This field is for validation purposes and should be left unchanged.

Vehicle Information:

Rental Company Contact Information: