CERTIFICATE OF INSURANCE REQUEST FORM

PENN STATE HEALTH

Table of Contents:

• Purpose
• General Information
  • Penn State Health Entities
  • University Park and Commonwealth Campuses
• Exhibit and Instructions
• Form Requirements
• Clearing Fill-and-Print Form Field Entries
• Number of Copies and Ultimate Distribution
• Where To Send Completed Forms
• Contact Information
• Cross References

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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, Penn State Health Life Lion, LLC, Lancaster Medical Center, Penn State Health, and Pennsylvania Psychiatric Institute 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 and Commonwealth Campuses:

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:

This form has fill-and-print form fields enabled. The PDF version has instructions provided for the type and/or format of information to be included within the fill-and-print form fields. Hovering the computer mouse over any form field within the PDF will display these instructions.

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 Associate Vice President for Budget and Finance). See Policy FN17 Required Use of Approved University Forms Appearing in the General University Reference Utility (GURU) and Procedure FN2017 Use of Forms Appearing on the GURU Website for full details.

Clearing Fill-and-Print Form Field Entries:

This form has the "Clear Form" bookmark enabled. To clear ALL form field entries:

• If left-hand column is not displayed when the document is opened, click the small arrow located at about the mid-point of the left-hand side of the screen to reveal the column
• Click "Bookmarks" (looks like a ribbon)
• Click "Clear Form"

If you encounter any difficulties, contact the GURU support staff by submitting a Technical Support Form request.

Number of Copies and Ultimate Distribution:

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:

• Policy AD35 University Archives and Records Management
• Policy FN17 Required Use of Approved University Forms Appearing in the General University Reference Utility
• Procedure FN2017 Use of Forms Appearing on the GURU Website

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