Evidence of Coverage Request
Former Students for potential employers
Full name of former student
*
First Name
Middle Name
Last Name
Dates of clinical/internship
Start date of clinical/internship
*
-
Month
-
Day
Year
End date of clinical/internship
*
-
Month
-
Day
Year
Is a loss letter also required?
*
Yes
No
Full name of person completing this form
*
First Name
Middle Name
Last Name
Email address of person completing this form
*
username@duq.edu
Phone number of person completing this form
*
-
Area Code
Phone Number
Designation of person completing this form
*
Employee
Faculty
Former Student
Placement Site
Employer
Potential Employer
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
Email address of the company, firm or organization requesting COI
username@duq.edu
Where should the COI (and loss letter, if applicable) be sent?
*
To the former student
To the requesting company, firm or organization
Other helpful information?
Select “Browse Files” to attach the document or specific wording used to request this COI.
*
Browse Files
Documents could include release information, contract language or similar.
Cancel
of
Submit
Should be Empty: