ATTACHMENT G
Request to Waive Insurance Coverage
In accordance with the University of Hawaii at Hilo, Agreement for Facility Use, all non-University
affiliated organizations utilizing facilities or grounds owned or operated by the University must provide a
certificate of insurance verifying the existence of the necessary liability coverage, including the coverage
of the University of Hawaii and the State of Hawaii, and their officers, employees, and agents.
The Chancellor or his/her designee who has jurisdiction over the subject facilities may waive this
insurance requirement, if necessary, when the activity serves the best interest of the University and
there is adequate showing of responsibility by the organization.
To be completed and submitted for approval by the scheduling officer:
Name of Organization:
Address:
Name of Responsible Person on the Day(s) of the
Event:
Email:
Phone:
Date(s) of Event:
Expected Attendance
Purpose of Event:
Room/Facility Requested:
Will alcohol be served?
Hours of Use:
Provide a detailed explanation regarding why the organization is requesting a waiver for insurance
coverage, to include 1) how the use of University facilities for the event serves the best interest of the
University; and 2) details demonstrating adequate responsibility by the organization:
Recommend approval: _____________________________ Date:___________________________
Scheduling Officer
Waiver for Insurance Coverage Approved Waiver for Insurance Coverage Denied
Reason denied:_______________________
____________________________________
__________________________________________ Date:_________________________________
Chancellor or Chancellor’s Designee
Revised 1/17