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Certificate of Insurance Online Request Form

 

If you have questions regarding this insurance request, please contact Risk Management at 1-2354.

DU Department Requesting:

DU Contact Name:

DU Phone Number:

DU Email:

Requesting Company Name:

Requesting Company Address:

Requesting Company Contact Name:

Project Description:

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

Location:

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:

Has your contract been approved by University Counsel?:

Yes No

Has your contract been approved by Risk Management?:

Yes No

Date or Duration of Project:

/ / to / /

Additional Comments: