Fillable BELMONT UNIVERSITY CERTIFICATE of INSURANCE REQUEST FORM Send (Belmont University)

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BELMONT UNIVERSITY CERTIFICATE of INSURANCE REQUEST FORM Send (Belmont University)

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***MUST BE TYPED***
BELMONT UNIVERSITY
CERTIFICATE of INSURANCE REQUEST FORM
Send this
completed form to:
RiskManagement@belmont.edu; certrequests@ajg.com
Today’s Da
te: ____________ Date Certificate of Insurance is Needed: ____________
(Please allow 5 business days to process)
Requestor Information
Named Insured:
Belmont University
Address/City/State/Zip:
1900 Belmont Boulevard, Nashville, TN 37212
Requester:
Office of Risk Management
Telephone Number:
615-460-5429
Fax
615-460-6980
Certificate Holder
Certificate Holder:
Attention:
Address:
City, State, Zip Code:
Phone:
Email:
ATTENTION: Please attach copy of the request and the contract from
your customer, vendor, supplier, etc., if available
Coverages Requested
Special Required Wording (Check all that apply)
General Liability
Additional Insured (if required by written contract)
Auto Liability
Loss Payee (if you are renting equipment or a building)
Workers Comp & Employers Liab.
Lessor of Vehicles (if you are renting a vehicle/van)
Excess Liability
Mortgagee (if you are buying / leasing a building)
Property
Vendor (the vendor will specifically request this)
Educators Legal Liability
Description of Event or Interest of Certificate Requestor (i.e.; Property Location, Event, Leased Equipment,
Description of Project including project/contract name and/or number, and duration) Must include dates.
Did Cer
tificate Requestor ask for a Waiver of Subrogation in the contract?
General Liability
Workers Comp & Employers Liab.
Auto Liability
Other
Please direct questions to: Risk Management at risk.management@belmont.edu; (615) 460-5429
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BELMONT UNIVERSITY CERTIFICATE of INSURANCE REQUEST FORM Send (Belmont University)

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Completed 17 August 2020

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