Request for Certificate of Insurance Form

Form

Please complete and submit the form.

REQUESTER'S INFORMATION


EVENT INFORMATION


RECIPIENT'S INFORMATION (Certificate Holder: the external agency requesting the Certificate)


* Is there a Contract or an Agreement between UD and the agency?
* Are there Special Insurance Requirements from the Agency?

If yes, list the agency's insurance requirements for the certificate or if necessary, email additional insurance requirements to EHSRM@udayton.edu. Verify with the agency the type of insurance coverage they are requiring UD to provide for this event.

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Contact Us

Environmental Health and Safety / Risk Management

Fitz Hall 125 
300 College Park 
Dayton, Ohio 45469 - 2904

937-229-4503