Certificate of Liability Insurance Request Form

Please fill out this form completely.
You will receive a copy of the Certificate of Liability Insurance via email from the Business Office within 1 week of submission.

Date Requested


Date Required


Your Name







Group using Facility


Date of Use


# of Students & Staff


Name of Facility Requesting Certificate:


Street Address


City, State, Zip


Purpose of Use

Send Certificate to:


Fax Number


Phone Number


Company Email


Comments or Special Instructions