Certificate of Insurance/Coverage Application

Type of Coverage*:

Workers' Compensation

Liability

Automobile Liability

Property

Dates of Coverage Needed*:

Example: 01/01/2013 - 01/05/2013

Name*:

Enter Name of Organization Here.

Issued To*:

What organization is this being issued to?

Oranizations Address*:

Where can the Certificate of Coverage be mailed to?

Email Address*:

Where can the certificate of coverage be emailed to?

Oranizations Phone Number*:

Where can you be reached at, if we have questions?

Event/Purpose of Certificate*:

Why do you need the certificate of coverage?

Risk Management
Email: Connie Smith, MS
Phone: 715-425-3344
Fax: 715-425-4980
25H North Hall

University of Wisconsin-River Falls · 410 S. 3rd Street, River Falls WI 54022 USA · Campus Information 715-425-3911