ࡱ> ]_\ 9bjbj *Tcc  83Ln!#T,  $"% Q 4(!  0lٸU >!0n!&&& n!& :  CERTIFICATE OF INSURANCE REQUEST FORM E-MAIL THIS DOCUMENT TO:  HYPERLINK "mailto:risk@uidaho.edu" risk@uidaho.edu Questions? Contact Risk Management 208-885-6177 Name of Requesting State Agency/Dept. University of IdahoDate:  FORMTEXT      Time:  FORMTEXT      (University) Personnel Initiating Request:  FORMTEXT      (University) E-mail Address:  FORMTEXT       (University) Fax #: Phone #:  FORMTEXT      (University) comments, if any:  FORMTEXT      Certificate Holder:  FORMTEXT       (Certificate Holder is non-State non-University entity requesting the certificate) Attention:  FORMTEXT       Address:  FORMTEXT       City, State, Zip:  FORMTEXT       Job, Location or contract /Ref. #:  FORMTEXT      Type Cert.:  FORMCHECKBOX  Liability  FORMCHECKBOX  Auto  FORMCHECKBOX  Property  FORMCHECKBOX  Other Does the contract contain an Additional Insured requirement? Yes  FORMCHECKBOX  No  FORMCHECKBOX  Contact University Risk (208) 885-6177 for pre-approval before checking YESDoes the contract require liability limits higher than $500,000? Yes  FORMCHECKBOX  No  FORMCHECKBOX  If so, what limits?  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Email contract and certificate request to:  HYPERLINK "mailto:risk@uidaho.edu" risk@uidaho.eduDESCRIPTION OF ACTIVITY FOR WHICH REQUEST IS INITIATED: (include who, what, where, why, number of participants) Coverage for xx description of activity xx. 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Text8Check2Check3Check5Check6Check7Check8Check9Text14Text15E\wt  Ul ABxsQi       BxsMeiAAll  BxsMeiAAll  76zl$\sU?,zQw#q[$BI*&D8 ;CFAK`\K1PV.QgS%5TIY9Ga'b%KeRhqhkldw6xX_WT/vr[k&mt I Sly_p#N/<v] @LA   @2UnknownG.[x Times New Roman5Symbol3. .Cx ArialM" Univers (W1)Arial9. . Segoe UIA$BCambria Math"1hUGUGBYY!4  2QHP?T"!xx /INFORMATION NEEDED FOR CERTIFICATE OF INSURANCEMarsh USA, Inc. Thiel, Erika (ethiel@uidaho.edu) Oh+'0$ P\ |   0INFORMATION NEEDED FOR CERTIFICATE OF INSURANCEMarsh USA, Inc.Normal$Thiel, Erika (ethiel@uidaho.edu)2Microsoft Office Word@F#@0?@ABCDEFGHIJKMNOPQRSUVWXYZ[^Root Entry F۸U`Data +1Table8&WordDocument*TSummaryInformation(LDocumentSummaryInformation8TCompObjr  F Microsoft Word 97-2003 Document MSWordDocWord.Document.89q