Tulane University - Certificate of Insurance Request Form

Department Name:

Department Contact:

Phone Number:

Email:

Name of Certificate Holder:

Certificate Holder Contact Name:

Certificate Holder Address:

CHECK WHICH COVERAGES APPLY:

General Liability

Required Limits:

$1M per occurrence

$2M per occurrence

Other:

Insert other required limits

Automobile Liability

Required Limits:

$1M per occurrence

$2M per occurrence

Other:

Insert other required limits

Workers' Compensation/Employers' Liability

Required Limits:

$1M per occurrence

$2M per occurrence

Other:

Insert other required limits

Medical Malpractice

Required Limits:

Insert amount of required limits

If for an individual, check which one applies:

doctor

resident

medical student

Name of individual, if applicable:

Fine arts/books on loan to Tulane

Loan begin date:

Loan end date:

Who will have risk of shipping to Tulane?:

Tulane

Owner

Who will have risk of shipping from Tulane?:

Tulane

Owner

Description of fine arts/books on loan to Tulane and schedule of values:

Equipment/Property on loan to Tulane

Loan begin date:

Loan end date:

Description of equipment/property on loan to Tulane (include make, model, serial number, if applicable):

Total value of equipment/property on loan to Tulane:

Special Requirements:

Certificate holder as additional insured

waiver of subrogation

30 day notice of cancellation

Other special requirements or language:

Is there a contract requiring insurance coverage?:

Yes

No

If no contract, state purpose of certificate:

Office of Insurance and Risk Management