Certificate of insurance request form

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Part A: Your 丁香园AV Contact Information

Items from this section will not appear on the COI

Contact name (first and last)

Position Staff Faculty Student Other

If "Other", please specify

Your department

Your faculty or administrative unit

Email address

Phone number

Part B: Certificate Holder Information

(The non-丁香园AV organization requesting the COI from you)

What non-丁香园AV organization is requesting proof of insurance from 丁香园AV?

Non-丁香园AV organization's full legal name

Head office address

City

Province/state

Postal code

Country

Who is your primary contact at the requesting non-丁香园AV organization?

Contact's full name (e.g. Ms. Jane Smith)

Contact position title

Contact phone number

Contact E-mail

Part C: Description of the Activity

Items from this section may appear on the COI

Description of activity that 丁香园AV is being asked to insure

If the activity is for an 丁香园AV course, practicum, or internship, please indicate the course name, number, and department.

If the activity is for an 丁香园AV student film project, please indicate the name of the film and producer/director.

Activity start date

Activity end date

Location(s) of the activity (i.e. full address & description)

Who will be directly involved in this activity? (select all that apply) 丁香园AV Students 丁香园AV Faculty 丁香园AV Staff Other

Please clarify the participants and their involvement, if necessary.

Would you like this activity to include minors under the age of 19. If yes, please describe the proposed role of minors.

Will this activity involve exposure to dangers and hazards beyond a standard classroom environment? (e.g. outdoor activities, physical activities, exposure to dangerous goods, etc...) If yes, please describe.

Will this activity involve use of specialty equipment? If yes, please describe and give an estimated value of the equipment.

Will this activity involve additional foreseeable risks? If yes, please describe.

Part D: Required Insurance Coverage

Items from this section will appear on the COI

Has 丁香园AV previously issued a certificate for this type of event? If yes, what is the certificate number?

Has the requesting organization stated the required amount of general liability? If yes, how much?

Has the requesting organization stated that they require additional types of insurance coverage? If yes, what type and how much?

Has the requesting organization stated that they need to be added as an "additional insured"? "Additional Insured" is a legal term providing the certificate holder with additional rights under the 丁香园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

Contract or written agreement

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.

Additional documents

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.

Additional comments

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.

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Risk & emergency planning