UNIVERSITY OF WISCONSIN
River Falls
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Risk Management
Certificate of Insurance/Coverage Application
Requester's Name
*
Email Address
*
Where can the certificate of coverage be emailed to?
Type of Coverage
*
Workers' Compensation
Liability
Automobile Liability
Property
Dates of Coverage Needed
*
Example: 11/1/20119-1/30/2020
Organization Name
*
Issued To
*
What organization is this being issued to?
Oranizations Address
*
Where can the Certificate of Coverage be mailed 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?
