CERTIFICATE OF INSURANCE REQUEST Exhibit

Penn State Health

Form Instructions

1. Check the Penn State Health Entity requesting the Certificate of Insurance. Options include:
• Hershey Medical Center
• Holy Spirit Medical Center
• Lancaster Medical Center
• St. Joseph Medical Center
• Hampden Medical Center
• Penn State Health
• Community Medical Group
• Penn State Health Life Lion, LLC
• Pennsylvania Psychiatric Institute
2. Select the date this form is being completed
3. Enter the name of the Penn State employee requesting the Penn State Health Certificate of Insurance
4. Enter the requesters' email address
5. Enter the requesters' office phone number, including area code
6. Enter the requesters' department name and complete mailing address
7. If Community Medical Group checked above, enter the name of the Community Medical Group entity
8. Enter the name of organization to receive the Certificate of Insurance
9. Enter the name of the individual at the organization to receive the Certificate of Insurance
10. Enter the complete address of the organization requesting the Certificate of Insurance, including building name and number, street address, city, state, and zip code
11. Enter the reason the Certificate of Insurance is being requested, include a brief description of event or activity, dates of event or activity, and include any required certificate wording
12. Check all coverages required (options include):
    • General Liability
    • Automobile
    • Workers' Compensation
    • Excess Liability
    • Property (leases, equipment, etc.)
13. Check this box if Additional Insured Required and check which coverage (options include):
    • General Liability Coverage
    • Automobile coverage
    • Property
14. Check Yes or No to indicate if this request is to renew an existing certificate