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Audit, Risk, and Compliance
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Certificate of Insurance Request
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Certificate of Insurance Request Form
Contact Information
Name
Required
Wright State Department or Organization
Required
Campus Address
Required
Attention To
Telephone Number
Email
Required
Certificate Holder Information – this is the party that receives the certificate
Contact Name
Required
Address
Required
Attention To
Contact Phone
Email
Required
Requested Type of Insurance and Limit
Type of insurance
Cyber
Crime
Fiduciary
Property
Fine Arts
Medical Malpractice
Pollution
General Liability
Auto Liability
Educator's Liability
Foreign Liability
Cyber Limit
Crime Limit
Fiduciary Limit
Property Limit
Fine Arts Limit
Medical Malpractice Liability Limit
Pollution Limit
General Liability Limit
Automobile Liability Limit
Educators Legal Liability Limit
Foreign Liability Limit
Additional Information
Is certificate holder requesting either of the following?
Additional Insured
Loss Payee
If requesting Additional Insured, list the entity or entities that should be listed
Please include any other information that is required to appear on the Certificate of Insurance per your contract.
Special Instructions
Leave this field blank
