Contact Information Name Required Wright State Department or Organization Required Campus Address Required Email Required Telephone Number Certificate Holder Information – this is the party that receives the certificate Organization Name Required Address Required Contact Name Required Contact Phone Email Required Contract/Event Start Date Required Contract/Event End Date Required Research Proposal Number Research Banner Grant Is the certificate holder required to be named as additional insured? Yes No Type of insurance General Liability Automobile Liability Cyber Liability Educators Legal Liability Medical Malpractice Liability Excess/Umbrella Liability Other Liability General Liability Cost Automobile Liability Cost Educators Legal Liability Cost Medical Malpractice Liability Cost Excess/Umbrella Liability Cost Explain what the 'Other' Liability Cost is and how much it is Please include any other information that is required to appear on the Certificate of Insurance per your contract. Leave this field blank