Certificate of Insurance Request

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Certificate of Insurance Request

If you are required to provide a Certificate of Insurance to a vendor, contractor, or other entity for any reason, please supply the following information to the Office of Risk Management.

Stetson University Information

The Office of Risk Management needs to know who to contact on campus and what the event, function or programs needs are. Please provide that information in this section.

Contact Information

Department Name

Email Address

Full Name

Phone Number

Event/Function/Program Information

Event/Function/Program Name

Dates of Event/Function or Contract

Contract Number or Lease Agreement Number

Value of Equipment Leased/Borrowed

Description of Equipment Leased/Borrowed

Type of insurance needed:

General Liability

Property

Auto Liability

Workers Compensation

Internship and Professional Liability

Other

If other, please explain.

Requestor's Information

Please provided the requestor's official company/organization information in this section to go onto the Certificate of Insurance. The official company name will be listed in certificate holder box. Please note that an electronic certificate will be sent via email, which then can be forwarded as needed.

Official Company Name

Street 1

(Attn.) Name

Street 2

Email Address

City

Phone Number

State

ZIP

Requestor is requesting to be named as an Additional Insured in regards to liability.

Requestor is requesting to be named as Loss Payee (only applicable if Stetson is leasing, renting or borrowing equip from requestor, or if this is bond/loan related).

Please attach a copy of any certificate of insurance requirements given to you by the requesting company or as shown per applicable contract/agreement.

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