Use the Certification of Insurance Request Form to obtain a University Certificate of Insurance when an individual or an organization with whom the University has entered into an agreement with requires proof of insurance. Northwestern State University certificates of insurance can only be issued in connection with a Written Agreement, Purchase Order, License, Permit, RFP, or other document that requires a certificate of insurance.

A certificate of insurance should not be issued to a third party who may be working on University property. If a third party vendor requires a certificate of insurance for work being done on University owned/leased property, please contact the Environmental Health & Safety Office.

Certificates of Insurance should be requested by University employees only, and should be requested at least 10 business days prior to when a certificate is required by the certificate holder and/or the start date of the agreement/contract. The University cannot guarantee that a certificate will be issued in a timely manner if the request is sooner than 10 business days. You will receive a complete certificate by way of e‐mail. The identified certificate holder will receive a certificate by e‐mail if one is identified, and if an e‐mail address is submitted. Certificates are typically produced within 3‐5 business days. Certificates are not mailed to a certificate holder.

Certificate Holder/Agreement Information

The Certificate Holder will be the individual or organization with whom your department has written Agreement, Purchase Order, Contract, License, Permit RFP or other written document that requires a University Certificate of Insurance. In order to produce a certificate that meets the requirements of the party with whom the University has an agreement, carefully review the agreement and provide complete information about the Certificate Holder (name, address, contact person and e‐mail) and the insurance requirements (insurance type, agreement start and end date, whether the certificate holder or other entity must be name additional insured and any other special conditions) that must be met.

Additional Insured Status requested by way of Written Contract or Agreement:

Please note that additional insured status can only be granted by way of written contract or agreement.

Your agreement with the outside entity will state whether or not additional insured status is required by that entity.

Additional insured status is usually found within the insurance section of the agreement with the party requesting the certificate of insurance. You will need to review your agreement before requesting additional insured status.

If you have any additional questions, contact Chelsea Eddington at scsmith062@nsula.edu or (318) 357‐4424.

Instructions for the Certificate of Insurance Request Form

Date: Enter current date

NSU Contact Information: This is the NSU requestor.

Name: This is the person requesting the certificate of insurance that works at NSU

Office Phone: This is the requestor’s NSU phone number.

E‐mail Address: Requestor’s NSU e‐mail address.

Insurance Required: What kind of insurance certificate are you requesting?

Why do you need the insurance certificate?

General Liability

Automobile Liability

Other: You must enter an explanation in the blanks provided.

Certificate Holder Information:

  • Third Party or Company Name: This is the company or entity that needs the certificate of insurance from the University. They are the reason you are requesting this certificate.
  • Contact Name: Need a person to contact in case there is a question about the insurance certificate. This assists ORM, in case they need questions answered.
  • Mailing Address: Needed to complete the insurance certificate.
  • Contact Phone Number: Please provide contact’s phone number, in case of questions.
  • Contact E‐mail address: Please provide a contact e‐mail address, so that contact can be made if necessary.

Additional Insured: If this certificate of insurance is requested by a company or entity and there is a contract, MOU, or agreement of any type, then that contract must be attached to the certificate of insurance request. Certificates of Insurance will not be issued by ORM without the contract attached.

Agreement Dates: Please list beginning and ending dates of the contract.

Reason for Certificate: Please indicate why you need the certificate of insurance.