Certificate of Insurance Request

For assistance in using this form please email: riskmanagement@uoregon.edu

This request form is intended for use by University staff only.
Certificate of Insurances are issued typically within 2-5 business days.
If you are an outside entity needing a certificate of insurance please work with your department contact.
If multiple certificates are required you must complete a request form for each certificate needed. Failure to do so will result in your requests not being processed.

Department Information

Department Name*

Your Name*

Your Email Address*

Department Contact Phone Number*

Certificate holder Information

In this section please indicate the certificate holder's information. This is typically the vendor or entity making the request for a copy of the University's insurance.

Certificate Holder Name:*

The name of the vendor or entity requesting the certificate. NOTE: Typically NOT UO. Please list the exact name as it should appear on the certificate per your contract provisions.

Certificate holder's street address:*

This is the vendor or entity's address that requested the certificated of insurance from your department.

Certificate holder's city:*

Certificate holder's state:*

Certificate holders zip code:*

Certificate holder email address:

Coverages & Limits

Please indicate the requested coverage(s) and their respective limit(s)

General Liability: $500,000 (Select Excess/Umbrella if requires 1M)

Excess Liability/Umbrella Policy

General Liability Excess Limit Amt Requested:

Please indicate the per occurrence and aggerate limits (typically 1M/2M)

Auto Liability

Liquor Liability

Host Liquor Liability/Alcohol

If this request is for an event that will serve alcohol using another service provider other than UO catering then the Permission to Serve Alcohol Request form must be completed. To learn more please visit:

If this request is for proof of insurance for approved departments that sell alcohol at UO main events or for catering services (Housing/Athletics) no further action is needed.

Property

Property value(s) amt must be listed

Please indicate the limits requested.

Fine Arts

Property Value of Fine Arts

If you selected Fine Arts; please enter the total value of property being loaned or rented.

Fine Art Loss Payee

Internship and Professional:$3,000,000/$6,000,000

Workers' Compensation

Cyber

Crime

Other coverage requested:

Certificate Holder's Interest (to be evidenced on the certificate)

Check if certificate holder requires to be listed as additional insured (excludes Workers Comp. Coverage and Fine Art)

Event Start Date:*

If there is no start date you may enter the policy year.

Event End Date:

Please list the name of the event or object:*

Note: If this is for a practicum, externship or for workers compensation coverage for a specific employee please list their full name and title.

Description of Event or Activity - As it should appear on the certificate*

This should reflect what you want to appear on the certificate. Please also include any additional insured language requirements.

Examples below are intended to be used as a guide for when you are entering the below information field:

Facility Use Agreement: University of Oregon will use facilities at _____ on ______ for ________. ____ is listed as additional insured as required by contract. (Failure to complete this section may result in your certificate being delayed or inaccurately issued).

Practicum/externships or Workers compensation coverage evidenced:

Jane Doe, University of Oregon Student, will be participating in an externship on ___ to ___ at _____.

Evidence of coverage for University of Oregon _____, MD, for duties within the course and scope of their employment at the University of Oregon.

Fine Art:

Must provide complete list of art work you wish to have insured. You may also reference an exhibit and attach the exhibit.

Please enter the description of operations/contract required langauge below:

Special Instructions/Notes:

If you have special instructions for your request or need to indicate insurance requirements please explain below.

Requirements for Issuing the Certificate of Insurance

The Vice President for Finance and Administration (VPFA) has delegated signature authority to specific individuals to sign particular types of contracts. Please see the VPFA Delegation of Contract Signature Authority page for details.

For requests to evidence alcohol at a University sponsored event departments are required to complete the Permission to Serve Alcoholic Beverages Form. More information regarding alcohol service at the University may be found online.

Is Your Contract Signed by PCS? (please select):*

All contracts for events and activities at the University of Oregon (on & off campus) must be signed and approved through Purchasing & Contracting Services (PCS) or by another UO authorized signator.

Select or enter value

PCS Contract number

Please list the submission number for your contract if the contract is being processed through PCS.

Contract/Agreement Copy

Please attach a copy of the contract or agreement.

Drag and drop files here or

Date Completed COI is Needed/Required

Rush request

Please check this box if COI request is for less than 24hrs. Please note that COIs typically take 2-4 business days. Certificates are generated by the UO's broker and may take additional time if you fail to attach a completed contract.

By checking this box you are indicating the certificate will need to be renewed due to the contract going beyond the current fiscal year. Please note that renewal certificates typically issue after July 5th and will be emailed to the department contact if this box is checked once they are available. If the contract in question will be renewed prior to July 1 date, you may be asked to submit a new request and attach a copy of the new contract/amendment.

This certificate will need to be issued again after July 1 of next year:

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