¶¡ÏãÔ°AV

Certificate of insurance request form

Part A: Your ¶¡ÏãÔ°AV Contact Information

Items from this section will not appear on the COI

Position

Part B: Certificate Holder Information

(The non-¶¡ÏãÔ°AV organization requesting the COI from you)

What non-¶¡ÏãÔ°AV organization is requesting proof of insurance from ¶¡ÏãÔ°AV?

Who is your primary contact at the requesting non-¶¡ÏãÔ°AV organization?

Part C: Description of the Activity

Items from this section may appear on the COI

Who will be directly involved in this activity? (select all that apply)

Part D: Required Insurance Coverage

Items from this section will appear on the COI

"Additional Insured" is a legal term providing the certificate holder with additional rights under the ¶¡ÏãÔ°AV policy. Generally, this status is only granted if it has been agreed to in a written contract. You may upload the written contract using the additional information section below. please note that American Hospitals or similar organizations cannot be added as Additional Insureds

Part E: Contract & Additional Information

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The total size of uploaded attachments can be no larger than 15MB
A contract or written agreement is required. If you do not have one in place, please contact Risk Management to discuss your request.
 
The total size of uploaded attachments can be no larger than 15MB
Please feel free to include any further documents or information that you feel may help facilitate this request.

Risk Management will contact you if additional information is needed in order to issue a certificate. Please allow a minimum of 3-4 business days for your COI request to be processed.