Request for Certificate of Insurance

REQUESTOR (Must be a Cal Poly Pomona Employee or Registered Student Organization)

Employee or Student Organization Requesting Certificate

Last Name

First Name

Email Address

Phone #

Job/Position Title

Department/Club Name

Division

Date Needed By

Off Campus Organization Information

Please provide the following information of the outside organization that needs the Certificate of Insurance.

Organization Name

Organization Address

Organization Contact Name

Organization Contact Email

Organization Contact Phone #

Format example: ###) ###-#### Please provide the extension number, if applicable.

Reason for Certificate

(Grant, Event, Contract, Lease, Agreement, etc.)

Special Instructions

If there is an additional insured request, please describe requirements and attach document or agreement.

File Attachments Upload

Drop your files here

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