Certificate of Insurance Request Form

  Smart Form Standard Web Part 2

Your Information

Name *

Phone *

Email *

Sponsoring Department *

DePaul Status * <Select One> Student Faculty Staff

 Certificate Holder

Name of Requesting Company/Vendor *

Address *

City *

State *

Zip Code *

Contact Name *

Contact Phone *

Contact Fax

Contact Email

Certificate Due Date *

Date

Event Details

Is the certificate for an event?Yes
No

Event Type *

Event Name *

Event Description *

Event Date *

Date

Event Time *

Event Location (Include address if different from company/vendor location) *

Certificate Information

Purpose of Certificate *

Please note any insurance requirements, terms or specifics here.

Is there an agreement or contract? *Yes
No

NOTE: Please send a copy of the agreement or contract prior to signing.

Any other supporting documents? *Yes
No

Attachment

NOTE: Risk Management requires a copy of the written contract or agreement if the certificate holder (requestor) is requesting to be named as "additional insured," "loss payee" and/or "mortgagee."

If you have any questions please contact us at insurancecertificate@depaul.edu.

Before clicking the Submit button, please take time to review the accuracy of your COI Request.

Thank you,
The Risk Management Team