Workers Compensation and Auto Liability Insurance

Requests for certificates of insurance for workers compensation and auto liability must be requested from the Nebraska State Risk Management Office.

Certificate of Insurance Request Form

The form below should be used by the State Colleges to request certificates of insurance for property and liability insurance required by third parties. Certificates should be requested at least three (3) days in advance of an event. Questions regarding Certificates of Insurance should be directed to Angela Melton, Vice Chancellor for Student Affairs & Risk Management at amelton@nscs.edu.

Date of Request

Date Needed By:

Name of Event, Activity, or Contract

Start Date of Event, Activity, or Contract

End Date of Event, Activity, or Contract

Requestor Information

First Name

Last Name

College

Telephone Number

E-mail

Email:

Email (Re-enter):

Certificate Holder Information - Exact name as it should appear on the certificate.

First Name

Last Name

Title

Entity

Address

Address Line 1

Address Line 2

City

State

Zip

Email:

Email (Re-enter):

Does anyone other than requestor and certificate holder need a copy? If so, please provide their email address.

What type of insurance policy/coverage is needed? (Select all that apply)

Liability Insurance

Property Insurance

Other

Amount of Coverage Needed

Please include a description of operations/location(s) and any additional remarks that should appear on the certificate. The text entered will appear on the certificate. (Example: Vendor is an additional insured on general liability on a primary and non-contributory basis as required by contract).

Will this certificate need to be sent again when the selected insurance policy renews? Most insurance policies renew on July 1.

Yes

Please attach the agreement or contract. Please note only one file can be attached. If you have multiple files, please combine into a single document or you can send them directly to amelton@nscs.edu

Additional Comments or Special Instructions