Certificate of Coverage Request

Date of Request*

(Today's Date)

Date Certificate is Needed By

Please give us a call at x3215 if the date requested is within 5 business days. We ask for a minimum of two weeks from Date of Request for processing.

Name of UW Oshkosh Employee Making Request*

First Last

Title of Employee Making Request

Employee's Department/Program Area

Name of Agency Requesting Certificate of Coverage*

Address of Agency Requesting Certificate of Coverage

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Date Range of Coverage Needed (up to 3 years for ongoing services, or event date(s) if for short-term event)*

Event Title and Brief Description of Event Activities*

Coverage Type(s) Requested by Agency*

General Liability
Automotive Liability
Property
Workers Compensation
Other

Select which type(s) of insurance the agency is requesting proof of coverage for.

List any additional coverage types, terms or conditions requested by the agency

Is a signed MOU, contract, or other agreement required for this event?*

Yes
No

Name of the UW Oshkosh employee with signature authority to sign the required agreement

First Last

Enter "N/A" if not applicable

Has the required agreement been approved and signed by the authorized signature authority listed above?*

Yes
No
N/A

Please let us know if you have anything else to add regarding this request.

Contact

Certificate of Coverage Request