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Certificate of Coverage Information Form

Directions: Complete all of the information requested on this electronic form and click submit below. The Office of Environmental Health, Risk Management & Safety will prepare the Certificate of Coverage using the information you provide. Please try to keep responses as brief as possible. If you experience difficulty using this form or have any questions, please call 472-1856. Thank you.

Type of Insurance Coverage Required
(Worker's Compensation, Liability, Automobile Liability, Property):

Dates of Coverage:

Person and/or Activity (Including Location) Coverage is Requested For:

Person or Organization (Including Address) Certificate of Coverage Should be Issued To:

Contact Information

Name of Contact Person:

Campus Phone Number:

Dept/Office:

Local Email Address: