Request for a Certificate of Liability Insurance
ROWAN REQUESTOR INFORMATION
Date of Request: Click here to enter a date.
Date Needed By: Click here to enter a date.
Name: Click here to enter text.
Department: Click here to enter text.
Phone: Click here to enter text.
E-Mail: Click here to enter text.
CERTIFICATE HOLDER INFORMATION
Company Name: Click here to enter text.
Street Address: Click here to enter text.
City, State & Zip Code: Click here to enter text.
Contact Person: Click here to enter text.
E-Mail: Click here to enter text.
ACTIVITY/EVENT INFORMATION
Description of the Activity/Event: Click here to enter text.
Start Date: Click here to enter a date.
End Date: Click here to enter a date.
Rowan Entity Name (e.g. College of Education, Tennis Club Sports Team, Intercollegiate Football
Team, etc.): Click here to enter text.
Rowan Student Name (Individual student rotations, internships, field placements, etc.): Click here
to enter text.
COVERAGE TO BE EVIDENCED
☐ Professional Liability
☐ General Liability
Note: Please attach a copy of agreement/contract along with this request and forward to:
Rowan University Office of Risk Management and Insurance
tartaglia@rowan.edu