Pdf all fields in red are required new york university

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Certificate/Evidence of Insurance Request Form
Email to: insurance.vendor.cert@nyu.edu
All Fields in RED are REQUIRED! Click for Definitions & Explanations
**** No Certificate of Insurance will be issued unless this Form is Fully Completed ****
** Attach Relevant Contract Documents and/or Expired Certificates **
Is there a Contract Agreement affiliated with this request? Yes No If Yes, send it along with this completed Form.
Has a current Contract been submitted to Insurance & ERM for review? Yes No
** All Contracts MUST be delivered to Insurance & Enterprise Risk Management after fully executed ***
Date: Requested By: Requesters Phone #: Faculty Group Practice? Yes No
Request Type: NEW RUSH (Need by Date) REISSUE
Named Insured to be shown on the certificate: Select One
New York University - (This does not include the School of Medicine)
New York University - (School of Medicine)
New York University - (70 Washington Square address required)
NYU Winthrop Hospital
NYU Langone Health System
NYU Hospitals Center
NYU Hospitals Center - dba New York University Hospital for Joint Disease
Other (Full Name & Address):
Certificate Holder Does this certificate need to be renewed annually? Yes No
Name:
Address Line 1:
Address Line 2:
City, State & Zip Code: City State Zip
Certificate Holder Contact: Name: Email:
Do you want a copy? Yes No Email:
Coverage (Check all boxes that apply)
Coverage Additional Insured Waiver of Subrogation
General Liability Limits:
Auto Liability Limits:
Workers Compensation
Umbrella/Excess Limits:
Professional Liability Limits:
Dental Professional Limits:
Liability
Other
Any other Comments or
Delivery Instructions?
Form Updated April 12, 2017
New York University - Insurance & Enterprise Risk Management - 105 East 17th Street, New York, NY 10003

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