Department of Counseling, Administration, Supervision & Adult Learning
College of Education
INTERNSHIP LIABILITY INSURANCE VERIFICATION FORM
Intern’s Name ____________________________________________
Degree Program School __________ Agency _________________
Internship Site name ______________________________
Address ______________________________________
Address ______________________________________
Phone ________________________________________
Email ________________________________________
Supervisor’s Name and Title/License ____________________________________
I hereby verify that I have liability coverage in at least one of the following ways (check all that
apply)
_____ The school or agency has liability coverage for me as an employee of the organization
_____ The school or agency has liability coverage for me as an intern, even though I am not a
regular employee of the organization
_____ I have obtained my own liability insurance through my membership in ACA, ASCA, or
other professional organization
_____ I have obtained my own professional liability insurance through my homeowners’/
renters’, insurance or other private insurance source
Signed ____________________________________ Date _____________________
Insurance Verification/rev. 2010