Request for Certificate of Insurance

Risk Management & Insurance

Request For Certificate of Insurance

This form is used when outside entities request information about MSU insurance which is referenced in a contract or agreement. The request must be submitted by an MSU Employee.

According to the Bylaws of the Board of Trustees of Michigan State University only specific individuals are authorized to sign/execute contracts and other legal documents (i.e. agreements, facility use permits) on behalf of MSU.

Review the language of any agreement, permit or document a facility/entity may require for the activity/event. If asked to indemnify or name an outside entity as additional insured do not sign - forward a copy to Risk Management and Insurance for review and consultation.

MSU Employee Information:

MSU Employee Submitting this Request:

Your Email Address:

MSU Department/College:

If MSU Extension Office - enter County:

MSU Phone Number:

MSU FAX Number:

Describe the MSU Program, Event, Grant, Contract:

Start Date (mm/dd/yyyy):

End Date (mm/dd/yyyy):

Certificate Holder Information:

Name of the Non-MSU Entity:

Non-MSU Entity Address:

Their Contact Person:

Their Phone # (123-123-1234 x 123):

Their FAX # (123-123-1234):

Comments:

Please allow 3 business days after submission for certificate to be faxed/mailed to the MSU Office making this request.

MSU Controller's Office

Risk Management & Insurance