Certificate of Insurance Request
University of Oregon
Office of Risk Management
Contact: Lisa Taylor, Insurance and Claims Coordinator
Please provide the information below to request a certificate of insurance. Certificates can typically be provided in 1-3 business days. If you have a rush request please complete this form and then email firstname.lastname@example.org to notify.
Please list the name of the event or object:
Note: If this is for a practicum or medical liability please list the student or employee's name and title.
Insurance start date:
If there is no start date you may enter the policy year.
Insurance end date:
Note: Insurance renewals take place at fiscal year end. If this is a multi-year contract a new certificate of insurance will be provided once the new policy is in place.
Description of Event or Activity
This should reflect what you want to appear on the certificate. Example: University of Oregon will use facilities at _____ on ______ for ________.
Department Contact Phone Number
Your Email Address
Certificate Holder Name:
Exact name as it should appear on the certificate.
Certificate Holder Address:
Certificate Holder Email Address:
What type of insurance is required? This is typically listed on the contract/facility use agreement under insurance. Select all that apply:
General Liability: $500,000 (Select Excess/Umbrella if requires 1M)
Auto Liability: $1,000,000 Self Insurance
Excess/Umbrella Liability: $5,000,000
Student Medical Professional:$1,000,000/$6,000,000
Employee Medical Professional: $5,000,000
Additional Insured? (please select):
If vendor requires specific clauses, please indicate below.
Both: Additional Insured and Loss Payee
If you selected Fine Arts or Property; please enter the total value of property being loaned or rented.
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.
In process, contract sent to PCS/UO authorized signator.
Date Completed COI is Needed/Required
Please attach a copy of the contract or agreement.
If you have special instructions for your request or need to indicate insurance requirements please explain below.
Send me a copy of my responses
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