Risk Mgmt - Evidence of Insurance Coverage Request (Students)

This form can be utilized to request Certificates of Insurance from students or former students.

Title

A short description to explain the nature of a ticket.

Evidence of Insurance Coverage Request (Students)

Full name of former student

Start date of clinical/internship

End date of clinical/internship

Is a loss letter also required?

Yes

Full name of person completing this form

Email address of person completing this form

Phone number of person completing this form

Designation of person completing this form

Street Address

Street Address Line 2

City

State / Province

Postal / Zip Code

Email address of the company, firm or organization requesting COI

Where should the COI (and loss letter, if applicable) be sent?

To the former student

To the requesting company, firm or organization

Other helpful information?

Select “Browse Files” below to attach the specific document or wording used to request this COI.

Attachment

File attachments associated with the ticket.

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Other Fields

Your name

Your email address

Verification Code