Certificate of Insurance Request Form
REQUESTED BY
NAME OF CERTIFICATE HOLDER
Manchester Community College
60 Bidwell Street, MS #10, Manchester, CT 06040
Number and Street Apt. # City State Zip
Please list
Please describe in detail Date of Event Date of Coverage
Insured/
State Agency
Address of
Certificate
Holder
Address of
State Agency
Additionally
Insured
Description
of Event
or Special
Information
First Name Last Name
First Name Last Name Date of Request
Email
Phone Number of Requester Fax Number of Requester
Please include the following as needed:
• FOR PROPERTY OR EQUIPMENT:
Year, make, model, serial #, VIN #, value
• FOR EVENTS:
Description of event, number of participants
• FOR FINE ARTWORK:
List each item with individual values
Please include any backup (i.e. insurance
requirements in contracts, lease agreements,etc.)
ADDITIONAL INFORMATION
If specific limits are needed, please indicate.
COVERAGE REQUIRED
Commercial General Liability $
Yes
No
Automobile Liability $
Yes
No
Automobile Physical Damage $
Yes
No
Property (please indicate amount needed to see): $
Yes
No
December 2016/PR
Please complete this form and email to Maria Generis at mgeneris@manchestercc.edu
