Certificate of Insurance Request

The University hosts events and activities throughout the year that may involve external service providers (contractors or vendors). Any external service provider working on University premises must carry valid insurance to cover potential claims or losses.

Requestor Information

Provide your contact details so the Office of Risk Management can confirm and file the Certificate of Insurance.
Name
Email
Phone Phone - ### - ### ####
Extension
Certificate Information

Provide the certificate details, including the certificate holder’s name and address, contact information, the nature and dates of the activity/contract, and who from the University community (students, staff, faculty) is involved.
Certificate Holder/Organization Name

Name of the organization or entity for which the certificate should be created,
i.e. Durham District School Board, Minister of Colleges, Universities, Research Excellence and Security, The Metropolitan Toronto Convention Centre Corporation
Confirmation of Contract/Agreement

Confirmation of Contract/Agreement I have confirmed that a contract/agreement is in place and will ensure it is filed within our department/faculty's records.
Attach Signed Contract/Agreement

Attach Files
If this certificate of insurance has been requested in the past, or if you have a copy of the previous COI, feel free to attach it for our reference.

Attach Files
Certificate Holder Address
Contact Name

Of the person to whom is asking for the certificate
Contact Title

Of the person to whom is asking for the certificate
Contact Phone Number

Of the person to whom is asking for the certificate
Contact Email

Of the person to whom is asking for the certificate
Nature of Operations

The activity taking place,
i.e. Student Placement, Securing Funding for the University, Contract or Agreement Obligations
Date(s) of Activity

Date(s) of the activity or term of the contract agreement
Who is Performing Activity

Who is performing and/or taking part in this activity from the University community e.g.; students, staff, faculty
Insurance Required

Indicate the required insurance coverage and amount (in dollars) that the external service provider must carry. Note: The required insurance coverage and dollar amount can be found or is outlined in the agreement.
Select the required insurance:

Select the required insurance: Liability Insurance Errors & Omission Insurance Property Insurance Excess Insurance Cyber Insurance Equipment Breakdown Other Other
What is the dollar amount required?
Kindly provide the insurance section from the contract/agreement by copying and pasting it for our reference.
Additional Comments or Notes

Certificate of Insurance Request

Certificate of Insurance Request

Requestor Information

Certificate Information

Insurance Required

Additional Comments or Notes