University of Southern Indiana Risk Management

REQUEST FOR CERTIFICATE OF INSURANCE

This form is for requesting certificates of insurance from the Office of Risk Management and Safety:

If you have an event/ task which requires submitting a certificate of insurance to an outside organization, please complete the form below. Your submission will be reviewed as soon as possible. Requests will be prioritized and you will be notified when your certificate of insurance can be completed. If you require immediate assistance, call Janet Duncan at ext. 7003, Peggy Norman at ext. 5004 or John Hunt at ext. 5366.

Certificate Request Information

* Required field

Type of activity/exposure:*

Non
Request for information
Request for assistance
Other

Description of service:*

Date requested:*

/ / (mm/dd/yyyy)

Contact person:*

Phone number:*

Banner account number:*

Please provide as much information as you can.

Confirm security code.
Please enter code shown in the image:*

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8600 University Boulevard - Evansville, IN 47712-3596 - 812/464-8600