Certificate of Insurance Request Form

Send completed certificate to:

Matthew Wamback
University of Massachusetts
Central Administrative Services
Treasurer's Office
333 South St.
Shrewsbury, MA 01545-4176
FAX: (774) 455-7592

Type of Policy Requested*

	General Liability Policy
	Leased Automobile Policy
	Directors And Officers
	Other (describe below)

Request Date*

Name*

Phone*

E-mail Address*

Date(s) of Event*

Request Description (other)

Certificate Holder*

Name and address

Additional Insured(s)

Other Recipients

Indicate fax or mail; list all names, addresses and fax numbers

* Indicates required field

Authorization

Enter the numbers you see into the empty box

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