Certificate of Insurance Request Form

Liberty University, Inc.

Use this form to request a Certificate of Insurance or Proof of Insurance as may be required by third party entities such as vendors, municipalities or government agencies with which you are doing business on behalf of Liberty University.

INSTRUCTIONS : First Print this Page then complete, then scan to email to rlwells3@liberty.edu.

Evidence of Insurance requested as

[   ] Certificate of Insurance or [   ] Evidence of Coverage (check one)

Legal Name and address of person/entity requesting a Certificate of Insurance:

________________________________________________

Address of Entity:

______________________________________, ___________________, __________, ________

Street                                                               City                               State            Zip

If requested to be included on the certificate of insurance or proof of coverage please check.

[   ] Additional Insurance Required

[   ] Loss payee (only applicable for property rentals or leases)

[   ] Waiver of Subrogation (usually only applicable when there is a contract involved)

  • if requested please include a copy of the contract.

Reason for Certificate of Insurance or Evidence of Coverage (check one - see bullet for additional required information, if any) :

[   ] Temporary use of a third parties facilities or land (usually for an event or film/video shoot)

[   ] Purchase or Lease of new Vehicle/Automobile for University business

  • Attached documentation containing VIN and cost of vehicle/automobile.

[   ] Rental of equipment or property

  • attach List of equipment/property with cost to replace

[   ] Short term lease of equipment or property (less than one year)

  • attach List of equipment/property with cost to replace

[   ] Long term lease of equipment or property (more than one year)

  • attach List of equipment/property with cost to replace

If a project name has been established for this, please provide the name of the project (i.e.. Winterfest 2013, March LU Recruiting at Such–n-Such Conference):

____________________________________________,

Dates of Event, Rental, or Use _____/______/_________ to _____/______/_________.

Name of person submitting this form to the Office of Risk Management:

____________________________________________, ______________________________, _________

Name                                                                           Indicate if Student, Faculty or Staff     Department