ࡱ> QSP  bjbjVV 4><<44wwwww84v(fhhhhhh$] "wwwLwwffJ062FbR0j,# ##w #4 =: Risk Management Department Request for Certificate of Insurance From Others Name of Person and ÿմ Department Requesting Certificate of Insurance: Name: Department: Phone Number: Fax Number: Insurance Requirements: (Check all that apply) Automobile Liability: $ Professional Liability: $ General Liability: $ Workers Compensation: $ Property Insurance: $ Other: $ Explain: Entity Requesting a Copy of ÿմϒs Certificate of Insurance: (A complete mailing address must be furnished) Name: Company: Address: City/State/Zip: Phone Number: Fax Number: Activity to take place, or relationship to company that is requesting Certificate of Insurance: The Purchasing department and the Office of the General Counsel have reviewed contract/Agreement/Permit. A copy of Supporting documentation is attached Yes____ Yes____ No____ No____ NOTE: This completed form must be received by the Risk Management Department least three (3) working days prior to the activity or event.       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