PENN STATE HEALTH CERTIFICATE OF INSURANCE
Systems and Procedures
A Division of The Corporate Controller's Office
IN

CERTIFICATE OF INSURANCE REQUEST FORM

PENN STATE HEALTH

Table of Contents:


Purpose:

The Request for Penn State Health Certificate of Insurance form is to be used when Penn State Health is working with an outside organization that has asked a Penn State Health entity to provide evidence of insurance.

General Information:

Penn State Health Entities:

Penn State Health entities, including Hershey Medical Center, St. Joseph Medical Center, Community Medical Group, Holy Spirit Medical Center, Hampden Medical Center, and Penn State Health Life Lion, LLC, requesting a Certificate of Insurance must complete the Penn State Health Certificate of Insurance Request Form.

Email requests to certificaterequest@psu.edu (include COI in the subject line) and attach completed form.

The completed certificate will be emailed by the Office of Risk Management to the requester. It is the requester responsibility to send the certificate to the organization.

The Office of Risk Management can only issue a Certificate of Insurance if all requested information has been provided on the form. Any incomplete or missing information will result in the request form being returned to the requester without a Certificate of Insurance being issued.

Penn State University:

See the Penn State University Certificate of Insurance Request Form page for information pertaining the completing a Certificate of Insurance (COI) at University Park or the Commonwealth Campuses.

Exhibits and Instructions

The form contains fill-and-print form fields. Hover the computer mouse over these form fields to reveal instructions for the information to be included within each form field.

To view a printed version of these form field instruction, click exhibit link below:

Penn State Health Certificate of Insurance Request Exhibit

Form Requirements:

No form may be used that substitutes for an approved official University form without prior review and approval by the steward of the form/central office, as facilitated by the Office of Systems and Procedures (designated representative of the Corporate Controller). See Policy FN17 Required Use of Approved University Forms Appearing in the General University Reference Utility (GURU) for full details.

GURU PDF forms are designed for use with Adobe Acrobat Reader or Adobe Acrobat Pro. Each browser (Chrome, Firefox, Internet Explorer, etc) has a built-in PDF viewer making it the default PDF viewer without asking users. These built-in viewers do not necessarily support all features required for PDF Forms. Similarly, many calculations are not supported by other stand-alone PDF readers (for example, Nuance). If you experience problems downloading or opening documents, right click on the link on the Forms Locator Screen, select 'Save Link As' (or similar language) and save the file. The document can then be opened in either Adobe Acrobat Reader or Adobe Acrobat Pro from the saved location.

The latest version of Adobe Acrobat Reader is available for free. Contact your IT support staff person for downloading assistance, if/as needed. An Adobe Creative Cloud (CC) account is also available to all Penn State students, faculty, and staff members, at no cost. Sign up for an Adobe Creative Cloud account at adobe.psu.edu. If Adobe Acrobat Pro better suits your needs, contact your IT support staff person for purchasing and installation assistance.

If you encounter any difficulties, contact the GURU support staff by submitting a Technical Support Form request or by calling the tech support line at 814-863-8592

Number of Copies and Ultimate Distribution:

Table of distribution and retention of the Penn State Health Certificate of Insurance form
Document: Ultimate Distribution: Retention Periods: Disposition Method:
Request for Penn State Health Certificate of Insurance form Office of Risk Management End of fiscal year + 2 years Paper document = Secure Bin disposal or Shred

Electronic document = delete document and empty recycle bin
Certificate of Insurance Requesting Office End of event + 2 years Paper document = Secure Bin disposal or Shred

Electronic document = delete document and empty recycle bin

Where to Send Completed Forms:

Completed forms are emailed to certificaterequest@psu.edu

Contact Information

For questions, additional details, or to request changes to this form, please contact Office of Risk Management

Cross References:


(2021July23)