Request for Property Insurance Coverage

The purpose of Property Insurance Coverage is to cover Brown owned property, or items that Brown is contractually obligated to provide insurance coverage for.

*Please note that there is a departmental deductible of $3,000 if items are damaged.*

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

Department Information:
Department Name: Date:
Contact E-mail Address: Phone:

Item(s) to be Insured: (Please indicate if you will be sending a separate sheet with itemized list)

1. Value:
2. Value:
3. Value:

Are the items owned by Brown University?
Yes
No
If no, please provide the name and address of the person/facility to which the item(s) belong:

Where will the items be located? Please provide address:

Dates Insurance Needed:
Date to be added:
Date to be deleted:

Is a Certificate of Insurance required:
Yes
No

If yes,
Address to send it to:

Is In Transit Coverage Necessary? (Insurance needed while traveling to/from a location)
Yes
No

Indicate PO# if newly purchased:

If yes,

Shipping From Name and Address:
Shipping To Name and address:

Please indicate any additional information here: