Attachment C: Request for Certificate of Insurance (.doc)

Attachment C: Request for Certificate of Insurance (.pdf)

Complete the form and fax to Risk Services in Oakland at (510) 987-0965. 

Risk Management Office
Division of Agriculture & Natural Resources
1111 Franklin St, 6th Floor
Oakland, CA 94607

Email: Oristine.Harris@ucop.edu
Phone: 510-987-0085
Fax: 510-987-0965

 Please return this completed form to:
Risk Management Coordinator University of California Division of Agriculture & Natural Resources 300 Lakeside Drive, 6th Floor Oakland, CA 94612-3560
Fax: 510-987-0965
REQUEST FOR CERTIFICATION OF INSURANCE
Responsible Division staff/member
Phone Number
County Name
Name of entity to whom certificate is to be issued
Address of entity
Effective time and date of the activity:
Expiration time and date:
(Note: Times and dates are required if the party is asking to be named as additional insured)
Fill in Each Category for Minimum Dollar Amount Limits Required (if these limits are not written in the agreement, please contact the party and ask them; they may need to contact their insurance agent):
Each Occurrence
$
Personal and Advertising Injury*
$
General Aggregate
$
Vehicles Owned, Non-owned and Hired*
$
*Include only if agreement and/or activity require its inclusion.
Is there an agreement that needs to be signed in order to secure the facility?
[ ] Yes [ ] No
If yes, please attach agreement.
If no, please complete Attachment D or Attachment E. (These forms can be found on the ANR Risk Management website.)
Is the party requesting to be named as an additional insured?
[ ] Yes [ ] No
Please attach agreement with detailed times and dates.
Name of the party asking to be named as additional insured (if different from above).
Name of University group or activity
Type of Event
30 days written cancellation or modification notice is standard with UC's self-insurance programs.