Certificate of Insurance Request

​​​​​​​​​​​​​A Certificate of Insurance is a document used to verify the University’s insurance coverage to outside parties. Risk Management provides the certificate as proof of insurance.

To request a COI, please submit the form below.​​ Please note Environmental Health & Safety (773-325-3344) does not manage this process and any questions should be directed to insurancecertificate@depaul.edu​.

 Smart Form Standard Web Part 2

Your Information

Name *You must specify a value for this required field.

Phone *You must specify a value for this required field.

Email *You must specify a value for this required field.

Sponsoring Department *You must specify a value for this required field.

DePaul Status * <Select One> Student Faculty Staff You must specify a value for this required field.

Certificate Holder

Name of Requesting Company/Vendor *You must specify a value for this required field.

Address *You must specify a value for this required field.

City *You must specify a value for this required field.

State *You must specify a value for this required field.

Zip Code *You must specify a value for this required field.

Contact Name *You must specify a value for this required field.

Contact Phone *You must specify a value for this required field.

Contact Fax

Contact Email

Certificate Due Date *

Date

Event Details

Is the certificate for an event?

Yes

No

Event Type *You must specify a value for this required field.

Event Name *You must specify a value for this required field.

Event Description * You must specify a value for this required field.

Event Date *

Date

Event Time *You must specify a value for this required field.

Event Location * You must specify a value for this required field.

Certificate Information

Purpose of Certificate * You must specify a value for this required field.

Please note any insurance requirements, terms or specifics here.

Is there an agreement or contract? *

Yes

No

You must specify a value for this required field.

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

Any other supporting documents? *

Yes

No

You must specify a value for this required field.

Attachment

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

Click the Submit button one time to request your COI.

If you have questions, please email insurancecertificate@depaul.edu.