WINTHROP UNIVERSITY
CERTIFICATE OF INSURANCE REQUEST FORM
To request a Certificate of Insurance or proof of “self-insurance” coverage, send a
written request along with this completed form to the Risk Management Department and
include a copy of the original document (contract, letter) requesting the information. The
written request should provide as a minimum the following information:
1. Requesting Department: ____________________________________________
2. Basic information as to the activity, services, or event to be covered:
__________________________________________________________________
__________________________________________________________________
3. Complete name, mailing address and the contact person to whom the certificate
should be issued:
__________________________________________________________________
COMPANY NAME
CONTACT PERSON
__________________________________________________________________
P.O. BOX
___________________________________________________________________________________________________
STREET ADDRESS
___________________________________________________________________________________________________
CITY – STATE – ZIP CODE
_________________________________________________/_________________________________________________
TELEPHONE / FAX NUMBER
