Certificate of Insurance Request Form

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Please read before completing the form:

Use this Request for University of Massachusetts Certificates of Insurance form to obtain a University Certificate of Insurance when an individual or organization with whom the University has entered into an agreement with requires proof of insurance. UMass Certificates of Insurance can only be issued in connection with a written Agreement, Purchase Order, Contract, License, Permit, RFP, or other document which requires a certificate of insurance.

Certificates of Insurance should be requested at least 10 business days prior to when a certificate is required by the certificate holder and/or the start date of your agreement. The University cannot guarantee that a certificate will be issued in a timely manner if the request is sooner than 10 business days. You will receive a completed certificate by way of email. The identified certificate holder will receive a certificate by mail and/or email. Certificates are typically produced within 24-72 hours.

Certificate Holder/Agreement Information:

The Certificate Holder will be the individual or organization with whom your department has written Agreement, Purchase Order, Contract, License, Permit, RFP, or other written document that requires a University Certificate of Insurance. In order to produce a certificate that meets the requirements of the party with whom the University has an agreement, carefully review the agreement and provide complete information about the Certificate Holder (name, address, contact person and email) and the insurance requirements (insurance type, agreement start and end date, whether the certificate holder or other entity must be named additional insured and any other special conditions) that must be met.

Additional Insured Status Requested By Way of Written Contract or Agreement:

Please note that additional insured status can only be granted by way of written contract or agreement. Your agreement with the outside entity will state whether or not additional insured status is required by that entity. Additional insured status is usually found within the insurance section of the agreement with the party requesting the certificate of insurance.

If you have any additional questions, please contact Matt Wamback at mwamback@umassp.edu or at (774) 455-7588

Certificate of Insurance Request Form

To request a certificate please complete the following:

Today's Date*

Your Name*

Your Phone*

Your E-mail Address*

Insurance Required:

Type of Policy Requested*

	General Liability
	Automobile Liability (lease or rental only)

Other, please specify

Certificate Holder Information:

Contact Name*

Individual or Company Name*

Mailing Address*

City, State, Zip Code*

Contact Email Address (if known)

Agreement Dates:

Start Date*

End Date*

Reason for Certificate:

Describe Activity or Event*

Reason the certificate is required. Please include the reference information such as a contract# or RFP#.

Additional Insured:

Requested by way of written contract or agreement*

	Yes
	No

If YES, list the entities that require additional insured status as identified in your agreement

Other Recipients:

Other Recipients

Recipients other than the Certificate Holder, who should receive the certificate by email:

* Indicates required field

Authorization

Enter the numbers you see into the empty box

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