Request for Custom Certificate of Insurance

Request for Custom Certificate of Insurance

Requestor (Must be LSU Employee)

A copy of the certificate will be sent to Requestor's e-mail address. If a COI is needed to loan art additional information is required and the Fine Art Loan form should be completed at: http://www.lsu.edu/riskmgt/forms/fine-art-loan.php.

Name (First Last)*

E-mail*

Must be LSU E-mail

Phone #*

Department Name*

Date Needed By*

Certificate Holder/ Organization Information

Certificate Holder/ Organization Name*

Certificate Holder/ Organization Address*

Certificate Holder/ Organization Contact E-mail

Certificate Holder/ Organization Contact Phone #

Does Certificate Holder need to be named as additional insured/ loss payee?

If your Certificate Holder is requesting to be added as an Additional Insured or Loss Payee, a complete copy of the contract, agreement, or lease must be attached with this request.

Yes

File Attachments (Please include a copy of the related agreement/event)*

Drag and drop files here or

Reason for Certificate*

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

Coverage and Coverage Limits

General Liability

General Liability Limit

Automotive Liability

Automotive Liability Limit

Educators Legal

Educators Liability Limit

Workers Compensation

Workers Compensation Limit

Other

Coverage Name- Other

Other Limit

For questions, please contact the riskmanagement@lsu.edu or 578-3283

Special Instructions

Data Authorization*

I authorize that all information provided on this form, including any and all personal, financial and academic data may be shared with the LSU Risk Management and university insurance carriers and vendors. This data will be securely retained indefinitely. To learn more about privacy at LSU, please see the LSU Privacy Statement.

Send me a copy of my responses

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