Certificate



Indicate Certificate Period*
University Contact Information
University Name*	University of Victoria
Contact Name*
Title & Department*
Contact Email*
Contact Phone*
Contact Fax*

Additional Information (not required)

Certificate Holder Contact Information
Organization Name*
Street Address 1*
Street Address 2*
City*
Province / State*
Postal Code*
Country*
Contact Name
Title
Phone Number
FAX Number
E-mail

What level of service do you require?*
Next Day Same Day Rush
Should we renew this certificate next year?*
Yes No

Describe the Nature of Operations for this Certificate
Specific Activity*	Type here:
Date(s) of Activity*	Type here:
Who is performing the activity?*
Location of activity

Limit(s) of Insurance Required
Do you require proof of General Liability insurance?	Yes No
General Liability $
Additional Insured	Yes No
Do you require proof of Errors & Omissions Insurance?	Yes No
Errors & Omissions $
Do you require proof of Property Insurance?	Yes No
Property $
Additonal Insured	Yes No

Do you require proof of Excess Property?	Yes No
Excess Property $

REQUIRED DATE
Please record any Special Instructions here:	Type here:

Once you have clicked on the Subit Form button your request will be sent directly to Ben McAllister, Risk Analyst, for processing. Thank you.