| Certificate of Insurance Request Form
This form is to allow the user
to request a Certificate of Insurance from the Executive Secretary of Risk Management
at 801-538-9560. You will receive, by email, a copy of the form you submitted. The signed certificate will be faxed to you and the Certificate Holder within 5-7 days. |
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An "*" asterisk indicates a required field.
Certificate Requestor
Information (Our Insured) |
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Organization: |
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Address: |
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City ,*
State: |
,
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Zip Code: |
(5 digits) |
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Phone Number: |
000-000-0000 |
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Fax Number: |
000-000-0000 |
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Email: |
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Confirm Email: |
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| Entity Requiring
Proof of Insurance (Certificate Holder) |
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Name: |
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*
Organization: |
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*
Address: |
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City ,*
State: |
,
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*
Zip Code: |
(5 digits) |
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Phone Number: |
000-000-0000 |
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Fax Number: |
000-000-0000 |
Email: |
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| Coverage Requested |
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Standard Government Liability Insurance
covers up to the current Government Immunity Limit
(GIL). |
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If higher Limits of Liability are needed, check the appropriate box and fill in the amount: |
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Aggregate
$
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Per Occurrence
$
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Other Liability
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Amount
$
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If you require Proof of Property Insurance please check the box and fill in the amount.
$
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If you require Proof of Auto Comprehensive and Collision please check the box and fill in the amount.
$
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Description:
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Please describe the reason for
the request. If this is for an event, please include who, what, where, when, why and how.
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