Please allow up to 1 week for processing.

The purpose of a Certificate of Insurance (COI) is to provide proof of coverage under Brown's insurance for University related events/activities. 

This form serves as a formal request for a COI from Brown University departments.  It is important that you fill out all of the fields on the form carefully as that is how it will be printed directly on the COI.  They are only valid for the dates specified on your request.

Be sure to ask if there is a contract or rental use agreement when securing the location of your event.   Insurance language in contracts must be reviewed prior to signing any agreement with "additional insured language" or other specific insurance requirements.  Contracts need to be reviewed and signed by those who are authorized to do so. 

Email  supporting documents, such as signed and approved contract as well as a previous COI for reference to I[email protected].  Please print a copy for your records.

Department Name: *

Date: *

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Contact Email : *

Phone Number:

Would you like a copy of the Certificate of Insurance emailed to you?: *

Yes

No

Is there an agreement or contract associated with this request?: *

Yes

No

Such as a facilities use agreement, rental agreement or contract, etc.

Who approved insurance language? Cannot be left blank: *

"Additional Insured" request require language review.

For example was the contract sent through BCM or has the language been review by someone in the Insurance Office? If no agreement, enter NONE.

A COI is needed for the following reason. This will be printed on the COI as you entered.: *

Indicate any language that must appear on the COI here.
For example: "Brown University's [department/event] to be held on [date] from [start time] to [end time] at [location]."

Date of Event - Indicate a "from and to" date for a limited time otherwise the COI is only valid for one day: *

Please indicate the name of the outside party (non Brown entity) requesting the COI (Certificate Holder): *

Phone Number:

Name of contact person representing the outside party (a non Brown person): *

Contact person's email address:

Name and address of Certificate Holder - Exactly as it needs to appear on the Certificate of Insurance: *

Please indicate the name and address exactly as it needs to appear on the Certificate of Insurance. Please note - this should not be a Brown University address. It should be an address for the outside party requesting the Certificate of Insurance.

Would you like the Certificate of Insurance sent directly to the outside party?: *

Yes

No

If yes, please provide an email address in the field above.

Please include any comments or other information below:

If a party is asking to be named as additional insured, please indicate that below, and email a copy of the contract showing the insurance requirement to [email protected]. If you are unsure, please check with the outside party.