Worksheet for Requesting

Certificate of Financial Responsibility

UNIVERSITY OF IDAHO

Office of Risk Management

PO Box 443162

851 Campus Drive AD209

Moscow ID 83844-3162

Phone (208) 885-7177, Fax (208) 885-9490 Email admaff@uidaho.edu

Completed form must be received two weeks in advance of proposed event to be considered for coverage. If you need assistance in completing this worksheet, please contact Carry Salonen at the above listed numbers.

Name of Person Making Request

Name
Address

Phone
Email

Name of Group/Program/Department Presented

Name
Address

Phone
Email

University of Idaho Sponsored?

Yes

Location Of Activity/Name of Facility/Certificate Holder

Name
Address

Date (s) of Activity

What is activity? Estimate who and how many people will be in attendance. What is

activity intended to accomplish? What is the duration of the activity?

Additional Insured Endorsement Required?		Yes		No
Additional Insured Endorsement in Favor of:	Name		Address

Return to Contracts

Return to Risk Management

Certificate of Financial Responsibility

Name

Address

Phone

Email

Name

Address

Phone

Email

Name

Address

Additional Insured Endorsement Required?

Yes

No

Name