Berklee Certificate of Insurance Request Form

Please complete all sections of this form to request a Certificate of Insurance. Incomplete forms may result in a delay in processing your request. Please keep in mind that processing can take up to two business days. If an endorsement is required, it may take up to a week. Please consider this timeline when planning your request.

If you have any questions or need assistance, please contact Mari Campusano at 617-747-6326 or at riskmanagement@berklee.edu.

Berklee Requester Information

First

Last

Title/Position

Department

Contact Number

Email Address

Other Party / Certificate Holder Information

Name of Certificate Holder

Address

Address 2

City/Town

State/Province

ZIP/Postal Code

Country

Contact Person's First Name

Contact Person's Last Name

Contact Number

Email Address

Purpose of Certificate

Reason for Request

Contract Requirement, Event, Vendor Agreement, etc.

Brief Description of Service/Event

Address of Service/Event

Address 2

City/Town

State/Province

ZIP/Postal Code

Date(s) of Service/Event

Insurance Requirements

Type of Insurance Coverage Required

Please list any other entities that need to be included as additional insured.

Additional Instructions or Information

Please provide any additional instructions or information related to the request.

Submission Details

Desired Completion Date

Signature

By signing below, I confirm that the information provided in this form is accurate and complete to the best of my knowledge.

Requestor Signature

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Today's Date

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