A data error has occurred. Larry or Randy has been notified.
Button color and preset tabs/native tab order was set based on the computer's identity, not the user's. The settings may not reflect what you want - but you can change them.
Button color and preset tabs/native tab order were set to default values. The settings may not reflect what you want - but you can change them.
Fix indicated fields
A data error has occurred. The administrator has been notified.
If your organization does not have a mailing address, use your campus' zip code.
The information they provide you will include insurance information. That's where you will find language stating they must be named as an additional insured. If it doesn't say that, leave this as "no."
If you are in doubt about an "unusual or increased exposure" it's best to describe the activity in Description of Event or select "yes" for unusual exposure and describe it in the provided area.
Use "no" for n/a.
Defined here as those recognized student groups who have a student organization account.

Office of Insurance, Loss Control & Claims

Request for Certificate of Insurance

This form is for the use of [1] recognized student groups who have a student organization account and [2] IU departments.

It may also be used by [3] student groups/organizations recognized by IU other than [1].

Many certificates of insurance can be issued without cost for Category [1] groups. If there is a cost you will be invoiced by INLOCC.

Category [2] groups will not be charged unless the event is deemed high risk (there could be an additional cost). You must include an account number.

Please note: Some events (those that are unusual or higher hazard - such as a large concert or aerial activity) are subject to the insurance carrier's review and acceptance. You will be notified if there are issues that must be addressed.

All certificates requested by Category [3] will have a cost that you must pay.

If there is a cost for the certificate you will have the opportunity to accept or decline the coverage before it is finalized. That message will come from INLOCC.

Please allow 10 working days to obtain the certificate. Allow 30 days if this is a significant event such as a large concert.

Attention IU departments: Contracts must be processed by Purchasing. Please forward the contract to them. They shall not be signed by you. Read the contract language to answer questions below.

Please review the form to ensure you have all required ( * ) information.

Recognized Student Group, IU Department or IU Affiliated Organization information

Is this an IU Department? |
Info

Requested By (you)


Outside Organization Making the Request

"n/a" is not an acceptable answer. If no one requested it you wouldn't be here filling out the form.


Additional Insured Status

You must read the contract to answer this and other questions.

| Info

Coverage Dates


Description of Event



Info

Unusual or Increased Exposure

Info |




Attendance

Is there a charge for attendance? |

Alcohol

|




|

Other Information

|
You must send us the contract. You will see further instructions after completing this form.
|
If the event involves SPORTS or RECREATION
activities, are waivers signed by participants?
| Info
If the event involves SPORTS or RECREATION
activities, is first aid available on site?
| Info

Account Information