CURIE CERTIFICATE OF INSURANCE REQUEST FORM

Please complete sections 2 and 7-9 and copy and paste it into an e-mail to pottles@yorku.ca
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Certificate Holder Contact Information
2a.  Organization Name*.........: 
2b.  Street Address.............:
2c.  City.......................: 
2d.  Province/State.............: 
2e.  Postal Code................: 
2f.  Country....................:
2g.  Contact Name*..............: 
2h.  Title......................: 
2i.  Phone Number*..............: 
2j.  Fax Number*................: 
2k.  E-Mailbox..................:


Describe the Nature of Operations for this Certificate
7a.  Specific activity*.........: 
7b.  Date(s) of activity........: 
7c.  Who is Performing activity.: 
7d.  Location of activity.......: 

Limit(s) of Insurance Required (Millions)
8a.  General Liability..........: 
8b.  Additional Insured (Y/N)...: 
8c.  Errors & Omissions.........:
8d.  Property...................:
8e.  Additional Insured (Y/N)...:
8f.  Excess Property............:

Please record any Special Instructions here.
9a.  Comments...................: