Environmental Health and Safety

Certificate of Insurance Request Form

Departments utilizing external entities who request a certificate of insurance from Cleveland State University prior to their use of facilities and/or properties need to provide CSU's Insurance/Risk Management representative with a copy of the contract or agreement document and complete and submit the Request for Certificate of Insurance form.

The documents must be forwarded to Cathie Chancellor, Risk & Insurance Administration Consultant fifteen (15) working days prior to the effective date of coverage.

CSU Insurance/Risk Management representative shall forward the original certificate of insurance directly to the requesting party and maintain a copy in the Office of Environmental Health and Safety. The CSU Insurance/Risk Management representative will be provided a copy of the certificate of insurance upon request.

Download: PDF icon  Certificate of Insurance Request Form 2017