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Certificate of Insurance Request
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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:
* Department Name:
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* Phone Number:
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* Email Address:
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* Reason for
Certificate of Insurance:
* Event Start Date:
spacer Calendar icon Select Date spacer * Event End Date: spacer spacer Calendar icon Select Date
Certificate Holder Information:
* Name of outside entity
requesting the Certificate
of Insurance:
* Mailing Address:
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* State:
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Zip:
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* E-mail Address:
* Contact person
representing outside entity:
* Outside entity contact person fax number:
- -
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* 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 No
* 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.
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Include any comments,
deadlines, or
other information:
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* 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