Certificate of Insurance

This form is intended to provide Undergraduate Student Association recognized clubs and organizations the ability to request Certificates of Insurance when required by vendors.

Submitting this form is a request, it does not guarantee that SA can provide this certificate.

You (requester) name:(*)

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What position do you hold within your club(*)

President

Vice President

Treasurer

Secretary

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Please choose your club(*)

Please choose your club from the list!

Your UB Email(*)

Please choose the type of event that best fits(*)

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Other:(*)

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When does your "setup" for this event begin?(*)

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When does this event begin?(*)

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When does this event end?(*)

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What time will you be done cleaning up your event?(*)

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Where are you holding this event?(*)

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Estimated number of people in attendance(*)

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Please attach a flyer for the event(*)

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COI Organization Info

Please enter the information below for the organization that requires the Certificate of Insurance.

Organization 1:

Name

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Address

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Phone Number

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350 Student Union, Buffalo, NY 14260
E ubsa@buffalo.edu
P (716) 645-2950
F (716) 645-2112