Certificates of Insurance

A Certificate of Insurance (COI) is a document that evidences specific insurance coverage for an entity. The COI provides confirmation of the required insurance and contains information on an insured's policies such as; limits of coverage, insurance company name, policy number, named insured, additional insured, the policy effective/term dates, etc. A COI is provided to third parties who require it in the course of doing business with the insured party.

Certificates are usually requested by opposite parties in an agreement, contract, or transaction to make certain the other party has the appropriate insurance coverage. A sample COI can be viewed by clicking here.

Ithaca College requires a COI when the College contracts with an outside party. The College's insurance requirements for third parties can be found by clicking here. However, these requirements are subject to change depending upon the scope of work. If you have any questions, please contact Risk Management.

There will be times when College departments are required to provide a COI to a third party for an off-campus event or activity. Please complete the Certificate of Insurance Request Form below at least 10 days prior to the scheduled event.

Student Media Production - Film Shoots

Please note: This is NOT the correct form to request a COI related to Student Media Production - Student Film Shoots. When an entity requests a Certificate of Insurance for a student shoot, please complete the Media Production - Film Shoot Request Form.

Please allow 10 business days to process the requested Certificate of Insurance. Complete all sections and be as detailed as possible. Thank you.

Date Requested:*

Name of Requester: (must be Faculty or Staff)*

First Name

Last Name

Department or Activity Requesting the Certificate of Insurance:*

Phone

Requestor Ithaca College Email Address: *

Is there a Contract or Agreement associated with this event or activity?*

Yes No

Please refer to the Ithaca College Contract Policy. You can also find information and instructions pertaining to Contracts at the Division of Legal Affairs.

Entity to Which Certificate of Insurance Will Be Issued

Be sure to provide the full address information, include contact person/department. Select the delivery mode for the Certificate of Insurance ie; fax, mail, email. (If you chose US mail please allow for additional mailing time)

Name of Entity: *

Attention:

Address*

Address Line 1

Address Line 2

City

State

ZIP Code

Phone

Mode of Delivery*

Email Fax US Mail

Entity Email Address

Entity Fax Number

Mailing address if other than listed above

Address Line 1

Address Line 2

City

State

ZIP Code

Provide a detailed description of activity, specify if location is on/off campus.*

Date/s of Activity*

Additional Insured Notation?*

Yes No Didn't Specify

If the Certificate of Insurance is to be sent to someone other than the entity listed, please include contact & delivery information here. A brief explanation of why/whom would be appreciated.

If the request is for equipment rental (ie: Ryder Truck, etc.) Include: year, make/model, VIN#/serial #, detailed description and replacement value.

Purpose of Rental