Certificate of Insurance Request

"*" indicates required fields

Submitter Name (SEU Employee)*

First Last

SEU Email Address*

Official Company Name*

Complete Company Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Company's Contact Name*

First Last

Company's Contact Email Address*

Company Phone Number*

Purpose of the COI (Event or Activity Description)*

Dates of Coverage Requested (Insurance Coverage Start and End Date)*

Use the policy year if there is no start and end date. Policy years begin on December 1 and end on November 30.

Is this COI request related to a contract/agreement?*

Yes

Please attach a copy of the contract/agreement.*

Max. file size: 10 MB.

Date COI is required by:*

Is the entity asking SEU to name their entity as an additional insured?*

Yes

Select