Certificate of Insurance Request Form

Name Required

Wright State Department or Organization Required

Campus Address Required

Email Required

Telephone Number

Organization Name Required

Address Required

Contact Name Required

Contact Phone

Email Required

Contract/Event Start Date Required

Month

Day

Year

Contract/Event End Date Required

Month

Day

Year

Research Proposal Number

Research Banner Grant

Is the certificate holder required to be named as additional insured?

Yes

No

Type of insurance

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.

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