Systems and Procedures
A Division of The Office of Budget and Finance
A Division of The Office of Budget and Finance
The Request for Certificate of Insurance form is to be used when The Pennsylvania State University ("University") is working with an outside organization that has asked the University to provide evidence of insurance.
The Penn State University Certificate of Insurance Request Form is to be completed if a Certificate of Insurance (COI) is to be issued on behalf of the University.
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 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 need to complete the Penn State Health Certificate of Insurance Request Form.
The form contains fill-and-print form fields. Hover the computer mouse of 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 University Certificate of Insurance Request ExhibitNo 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 Approved Form Templates Appearing on the GURU Website for full details.
| Document: | Ultimate Distribution: | Retention Periods: | Disposition Method: |
|---|---|---|---|
| Certificate of Insurance Request 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 fiscal year + 2 years | Paper document = Secure Bin disposal or Shred Electronic document = delete document and empty recycle bin |
Completed forms are emailed to certificaterequest@psu.edu (include COI in subject line) and attach completed form.
For questions or additional details, please contact the Office of Risk Management
To request changes to this form, please contact of the Office of Systems & Procedures by submitting a GURU Technical Support Request form.