Request for Certification of Insurance

✻ = Required

Requesting Party/Preparer Name

(Not Name of a Club)
✻

Requesting Party/Preparer's Email Address ✻

Phone Number ✻

Fax Number ✻

Responsible Division Staff/Member ✻

County Name ✻

Name of entity to whom certificate

is to be issued ✻

Address of Entity -

City, State & Zip ✻

Effective Date & Time of the Activity: ✻

Expiration Date & Time of the Activity: ✻

Coverage types and amounts

Fill in Each category for minimum dollar amount limits required i.e. $1,000,000 (if these limits are not written in the agreement, please contact the party and ask them; they may need to contact their insurance agent)

Each Occurrence ✻

Personal and Advertising Injury*

Products and Completed Operations Aggregate ✻

General Aggregate ✻

Vehicles Owned, Non-owned and Hired*

*Include only if agreement and/or activity require its inclusion.

Is there an agreement that needs to be signed in order to secure the facility?
(if yes please attach agreement)
(If no, please complete Attachment D or Attachment E)

Yes No

Is the party requesting to be named as an additional insured?
(Please attach agreement with detailed times and dates.)

Yes No

Name of the party asking to be named as additional insured (if different from above)

Name of University group or activity

Type of event ✻

30 days written cancellation or modification notice is standard with UC's self-insurance programs.
Attach all supporting documents below

Comments/Notes:

Upload your file(s)

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