University Corporate Insurance

In certain situation, Faculties/Departments are required to provide proof of General Liability insurance to external organizations. A Certificate of Insurance is generally held to be sufficient documentary evidence of an in force insurance policy.

Certificates are most commonly requested for students on workplacements as part of their studies at Western and for University sponsored events held off Western premises.

Requests for certificates must be received directly from Faculties/Departments. In some situations, a copy of an agreement/contract will be requested from the Corporate Insurance office before a certificate can be issued. Certificate image

Request for a Certificate of Insurance

Please enter all known information. When complete, click SUBMIT to send the request to the University Corporate Insurance office. When the certificate has been issued, the Corporate Insurance Administrator will contact you.

University Contact Information

Name: (required)

Department:

Phone #: Fax #:

Email: (required)

Certificate Holder Contact Information

Organization name:

Address:

City: Prov/State:

Postal Code: Country:

Contact name:

Title:

Phone #: Fax #:

Email:

Describe the Nature of Operations for this Certificate

Specific Activity:

Date(s) of Activity:

Who is performing the Activity?

Location of Activity:

Amount of General Liability Insurance required: $

(Note: If amount is unspecified, $2 million will be used for the certificate.)

(If the certificate holder is requesting to be listed as additional insured, please provide details in the comment area below.)

If you require proof of any other insurance, please contact the Corporate Insurance Administrator at (519) 661-2111 x85889 pacton@uwo.ca

Do you have a contract for this activity? YES NO

(Note: If you answered YES, the University Corporate Insurance office may request a copy of the contract prior to the Certificate being issued.)

Please record any other comments here:

Please note: Events at Which Alcohol may be Served
Students, staff or faculty holding events at which alcohol will be served, whether on or off-campus, must submit a "Proposal for Event" - see Campus Alcohol Policy (1.33) Appendix A