PENN STATE UNIVERSITY CERTIFICATE OF INSURANCE REQUEST FORM

University Park and Commonwealth Campuses

Form Instructions

1. Select the date the Certificate of Insurance is being submitted
2. Enter the name of the Penn State University employee requesting the Certificate of Insurance
3. Enter the requestors Penn State email address
4. Enter the requestors office phone number, including area code
5. Enter the requestors campus, college, or business area
6. Enter the requestors complete departmental address including building name, street address, city, state, and zip code
7. Enter the name of the non-Penn State University organization requesting the Certificate of Insurance
8. Enter the name of the individual at the non-PSU organization to receive the Certificate of Insurance
9. Enter the complete address of the organization requesting the Certificate of Insurance, including street address, city, state, and zip code
10. Provide a reason the Certificate of Insurance is being requested including a brief description of event or activity, date of event or activity, and include any required certificate wording
11. Check all appropriate types of coverages required. Options include:
    • General Liability
    • Automobile
    • Workers' Compensation
    • Excess Liability
    • Property (leases, equipment, etc.) NOTE: Property cannot be added to a standard COI. PSU will issue a letter from the Office of Risk Management evidencing requested coverage
12. Check this box if additional insured required and check the appropriate types of coverages required. Options include:
    • General Liability
    • Automobile
    • Property
13. Check Yes or No to indicate if this request is to renew an existing certificate