Seattle Pacific University

CERTIFICATE OF INSURANCE REQUEST

 

From:

 

Name/Dept -

Contact Info. (Phone/Email):

 

Certificate Holder: (Name & Address)

 

(This is the vendor)

Attn:

 

 

 

 

 

 

Fax #/ Email:

 

Description of Activity: (Reason for Cert Request)

 

 

 

Need to send to Certificate Holder (Y/N):

 

 

Please check coverages required for the certificate:

General Liability(Y/N)

 

 

Limits:

$

Auto Liability(Y/N):

 

 

$

Additional Insured? (Y/N):

 

 

Additional Insured Name if different from Certificate Holder:

 

 

 

Other/Comments:

 

 

Requested by:

 

Date:

 

Phone #:

 

 

 

 

 

Submit Form by email to Jordana Ross, jross@spu.edu

If you have questions please call x2461.