Certificate of Insurance

If you have questions regarding this insurance request, please contact Jennifer Kogovsek at Jennifer.Kogovsek@du.edu or 1-2354.

DU Department Requesting:

DU Contact Name:

DU Phone Number :

DU Email :

Requesting Company Name:

Requesting Company Address :

Project Description: Provide a detailed description, include type of event i.e., speaking engagment, stage play/theater, recital, wedding, etc.:

Location:

Is This a TULIP Request?

Yes No

How Many Attendees?

Will Alcohol Be Served?

Yes No

Yes No

If requesting a certificate of insurance, what insurance and limits does your contract require?

Workers' Compensation
General Liability
Auto
Property
Professional
Should they be named as additional insured?
Other - Please Explain:

If you are requesting a Certificate of Insurance, has your contract been approved by University Counsel?:

Yes No

If you are requesting a Certificate of Insurance, has your contract been approved by Risk Management?:

Yes No

Date or Duration of Project:

/ / to / /

Additional Comments: