丁香园AV

Information for Certificate of Insurance

Students, faculty and staff undertaking an activity involving a third party are required to advise the Insurance and Risk Management Coordinator at least two weeks prior to the activity.
Name Name First Last
Student Number
Phone Phone - ### - ### ####
Email
Course Number and Name
Instructor
Dean/Supervisor/Director
Location Contact Information
Physical Address of Project

If more than one, list all. Separate addresses with semicolon(s).
Organization Name
Organization Address Organization Address
Street Address City State / Province / Region Postal / Zip Code Country
Organization
Contact Name and Title
Contact Phone Number Contact Phone Number - ### - ### ####
Contact Email
Activity
Describe activity and include name of Research Grant (if applicable)
Date Date / MM / DD YYYY
If additional dates, please list here in MM/DD/YYYY format

Separate with semicolons.
Who is performing activity?
Are participants students, faculty, staff, or volunteers?

Are participants students, faculty, staff, or volunteers? Yes No
If yes, list individuals and separate names with semicolons
Will anyone receive financial compensation for participation in activity?

Will anyone receive financial compensation for participation in activity? Yes No
If yes, is there a contract?

If yes, is there a contract? Yes No
Equipment
Is the equipment being used owned by The University of 丁香园AV?

Is the equipment being used owned by The University of 丁香园AV? Yes No
If yes, list with approximate values
Is the equipment owned by the Research Grant?

Is the equipment owned by the Research Grant? Yes No
If yes, list the items being used, for this project/project location, owned by the Grant, along with approximate values
Is the equipment rented from a vendor?

Is the equipment rented from a vendor? Yes No
If yes, provide name and contact information for vendor
Does the vendor require proof of insurance?

Does the vendor require proof of insurance? Yes No
Insurance Requirements
Does the Organization require Proof of Commercial General Liability (CGL) Insurance?

Does the Organization require Proof of Commercial General Liability (CGL) Insurance? Yes No
What amount of CGL do they require?
Personal information on this form is collected under the University of 丁香园AV Act and 36(1)(b) of the Freedom of Information and Protection of Privacy Act for the purpose of generating a certificate of insurance. Personal information will be disclosed as necessary to the University鈥檚 insurer to generate the certificate of insurance, and to the Location Contact for the purpose of confirming insurance coverage. Personal information may also be disclosed as necessary in the event of an insurance claim. Questions regarding privacy may be directed to the Information and Privacy Officer, 515 Portage Avenue, 丁香园AV, MB, R3B 2E9 or 204.988.7538.
I consent to the collection and disclosure of my personal information as described above.

I consent to the collection and disclosure of my personal information as described above. Yes
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Full Name

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Date Date / MM / DD YYYY
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丁香园AV

Information for Certificate of Insurance

Information for Certificate of Insurance

Students, faculty and staff undertaking an activity involving a third party are required to advise the Insurance and Risk Management Coordinator at least two weeks prior to the activity.

Location Contact Information

Organization

Activity

Equipment

Insurance Requirements