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Certificate of Insurance Request Form
Contact Information
Name
Required
Wright State Department or Organization
Required
Campus Address
Required
Email
Required
Telephone Number
Certificate Holder Information – this is the party that receives the certificate
Organization Name
Required
Address
Required
Contact Name
Required
Contact Phone
Email
Required
Contract/Event Start Date
Required
Month
Month
Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
Day
Day
1
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31
Year
Year
2022
2023
2024
2025
2026
Contract/Event End Date
Required
Month
Month
Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
Day
Day
1
2
3
4
5
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31
Year
Year
2022
2023
2024
2025
2026
Research Proposal Number
Research Banner Grant
Is the certificate holder required to be named as additional insured?
Yes
No
Type of insurance
General Liability
Automobile Liability
Cyber Liability
Educators Legal Liability
Medical Malpractice Liability
Excess/Umbrella Liability
Other Liability
General Liability Cost
Automobile Liability Cost
Educators Legal Liability Cost
Medical Malpractice Liability Cost
Excess/Umbrella Liability Cost
Explain what the 'Other' Liability Cost is and how much it is
Please include any other information that is required to appear on the Certificate of Insurance per your contract.
Leave this field blank
