Fillable BELMONT UNIVERSITY MOTION PICTURES PROGRAM CERTIFICATE of INSURANCE (Belmont University)

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BELMONT UNIVERSITY MOTION PICTURES PROGRAM CERTIFICATE of INSURANCE (Belmont University)

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***MUST BE TYPED***
December 1, 2018
BELMONT UNIVERSITY – MOTION PICTURES PROGRAM
CERTIFICATE of INSURANCE REQUEST FORM for OFF CAMPUS FILMING
Send this completed form to: To your course instructor by email and to
RiskManagement@belmont.edu; certrequests@ajg.com
Student’s Name_____________________________ Class & Professor _______________________________
Student’s Email & Phone______________________________________________________________________
Today’s Date: ____________ Date certificate of insurance is Needed: ____________
(Please allow at least 5 business days to process)
Named Insured:
Belmont University
Address/City/State/Zip:
1900 Belmont Boulevard, Nashville, TN 37212
Requester:
Motion Pictures Program
Telephone Number:
615-460-5429
Fax
615-460-6980
C
ertificate Holder (Location of shoot)
Certificate Holder:
Attention:
Address:
City, State, Zip Code:
Phone:
Email:
ATTENTION: Please attach copy of the request and/or the contract from your location, if available.
Coverages Requested
Special Required Wording (Please describe – may delay processing
as it requires pre-approval)
General Liability
Inland Marine
Description of Production and rough schedule, including dates and times.
Did Certificate Requester ask for Additional Insured or Waiver of Subrogation? Any requests require
approval from Risk Management.
Please direct questions to your course instructor.
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BELMONT UNIVERSITY MOTION PICTURES PROGRAM CERTIFICATE of INSURANCE (Belmont University)

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Completed 17 August 2020

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