Office of Risk Management
CERTIFICATE OF INSURANCE REQUEST
Notice: Standard turn-around time is 3 to 5 business days. Requests with special circumstances may take
up to 14 business days. If the certificate is for a special event, submit your request 2 weeks prior to the
event. Attach any pertinent insurance documents with your request.
Requestor Information
Department:
Name:
Telephone / Extension:
Email:
@westernu.edu
Fax Number:
Reason for Request
Off Campus event
Contract Requirement
Leasing Requirement
Equipment Rental
Other
Proof of Coverage For
Western University
Faculty
Students
Employees
Type of Coverage
General Liability
Professional Liability
Property
Auto
Workers Compensation
Third Party Information (Certificate Holder Information)
Organization:
Contact Person:
Address:
City, State, Zip:
Telephone:
Fax:
To be named as Additional Insured:
Email:
Yes
No
Additional Information (i.e. specific insurance wording , name, event name & date, location, leasing number,etc.):
Office of Risk Management, Attn: Chique Magsino
Email: cmagsino@westernu.edu or fax to 909.469.5384
Revised 02-27-08
Office of Risk Management
Office of Risk Management, Attn: Chique Magsino
Email: cmagsino@westernu.edu or fax to 909.469.5384
Revised 02-27-08