Evidence of Coverage (Certificate of Insurance) for departmental requests

Evidence of Coverage (Certificate of Insurance)

For departmental requests
Full name of person completing this form *

First Name Middle Name Last Name
Designation of person completing this form *
Department or Field of Study for person completing this form *
Email address of person completing this form *
username@duq.edu
Phone number of person completing this form *

Area Code Phone Number
Name of the company, firm or organization requesting COI *
Mailing address of company, firm or organization requesting COI *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Does Duquesne University Legal Affairs have a contract or agreement in process for this request? *

Yes No
Every event, program, or activity must be accompanied by a contract or agreement that has been processed through Legal Affairs. Upon receipt of this request, you will be contacted to discuss the affiliate contract or agreement. If you have questions, please contact the Risk Management Office.
Is this request for one specific event, program or activity? *

Yes No
Please submit separate requests for each specific event, program, or activity.
Select “Browse Files” below to attach the specific document or wording used to request this COI. *

Browse Files
Documents could include release information, contract language or similar. Cancel of
Should be Empty: