CERTIFICATE OF LIABILITY INSURANCE REQUEST FORM
Date:___________________
Please use this form to submit a request for a Certificate of Insurance. Please return this form with a copy of the certificate/insurance
requirements from the organization requesting the certificate (if applicable) to:
Business Services & Facilities
536 Mission St
San Francisco, CA 94105
Fax: 415 495-2671
For any questions, please call Business Services at 415 442-7089 (9:00 am – 5:30 pm Mon-Fri).
Requester (GGU staff or faculty requesting):
Name:_______________________________________ Department:________________________________
Telephone: ______________________ Fax:______________________ Email: ________________________
Certificate Holder Information (To whom the Certificate of Insurance is to be issued to):
Company Name: _____________________________________ Attention: _____________________________
Address:_______________________________________ City:___________________ State:_____________
Zip:___________________
Telephone: ______________________ Fax:______________________ Email: ________________________
Additional Insured Requested: YES NO
If YES, Specify which policies and give details below:
Description/Reason for Certificate:
Event Name (if applicable):______________________________________ Event Date(s):________________
Event Location-City and State (if applicable):_____________________________________________________
Description of the Event:_____________________________________________________________________
Distribution of the Certificate:
The Certificate Holder will receive a copy of the certificate via fax and the original certificate by mail with the
information provided above. Please be sure to provide all requested information to prevent processing delays.
Additional Comments (Please give any additional instructions you feel appropriate for this certificate):
