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 NameMiddle NameLast 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*
Please enter a valid 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

CityState / Province

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

YesNo
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?*

YesNo
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.*

Documents could include release information, contract language or similar.
Cancelof
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