CSU Stanislaus | Risk Management | Certificate of Insurance Request

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Certificate of Insurance Request

Please complete the form below and print a copy for your records.

The purpose of a Certificate of Insurance is to provide proof of coverage under California State University, Stanislaus’ insurance for off-campus University-related events.

* This form serves as a formal request for a Certificate of Insurance. It is important that all fields are completed to ensure an accurate Certificate. Please contact the Risk Manager with any questions.

University Department Information:

* University Department Name:

* Department Contact Name:

* Phone Number:

- -

* FAX Number:

- -

* Email Address:

* Reason for
Certificate of Insurance:

* Event Start Date:

Select Date

* Event End Date:

Select Date

Certificate Holder Information:

* Name of outside entity
requesting the Certificate
of Insurance:

* Mailing Address:

* City:

* State:

Zip:

* Contact person
representing outside entity:

* Limits requested:
(Select only those required
by the contract.)

	$1,000,000 Commercial General Liability
	$2,000,000 General Liability Aggregate
	State Statute Workers' Compensation
	Other (list)

Does the Certificate Holder
want to be named
additional insured?:

Yes

* If a party is asking to be named as an additional insured,
please E-mail or FAX: (209) 667-3104 a copy of the contract or document
showing the insurance requirement.

Include any comments,
deadlines, or
other information:

* Please allow ten business days for processing.
The certificate will be e-mailed in pdf format to both the requesting University department
contact person and the outside entity contact person.

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California State University, Stanislaus
One University Circle
Turlock, CA 95382