Request for Certificate of Insurance

Please complete the form below, print a copy for your records, and e-mail or fax any supporting documentation to 863-1566.

The purpose of a Certificate of Insurance is to provide proof of coverage under Brown's insurance for University related events.

*If a party is asking to be named as an additional insured, please fax a copy of the contract showing the insurance requirement to 863-1566.

This form serves as a formal request for a Certificate of Insurance from Brown University departments. It is important that you fill out all the fields of the form. If you have any questions regarding Certificates of Insurance, please contact the Insurance Office at 863-9481.

Department Information:
Department Name: Date:
Contact E-mail Address: Phone:
Fax:
Would you like a copy of the Certificate of Insurance faxed to you? Yes No

A Certificate of Insurance is needed for the following reason (Indicate any language that must appear on the Certificate of Insurance here):

For example "Brown University's [department/event] to be held on [date] from [time] to [time] at [location]."

The dates of the event / dates coverage is needed are to

Certificate Holder Information:

Please indicate the name of the outside party (non Brown entity) requesting the Certificate of Insurance: . Their telephone number is . Their fax number is .

Please indicate the name of the contact person representing the outside party (a non Brown person) :
If they have an email address, please indicate that here:

Please indicate the name and address exactly as it needs to appear on the Certificate of Insurance (Required in order to process request)**Please note - this should not be a Brown University address. It should be address of the outside party requesting the Certificate of Insurance.**:

Would you like the Insurance Office to fax the outside party a copy of the Certificate of Insurance?
Yes No

Please include any comments or other information below:

Please allow up to 1 week for processing.