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Risk Management

Request for Certificate of Coverage

(Note: Certificates are only issued through June 30, 2013 due to possible change in rates past this date)

Please complete the below form to request a Certificate of Coverage. A certificate will be issued within five business days after receiving a properly completed form. It is the responsibility of the JMU department requesting the certificate to forward the certificate to the organization/business that needs the certificate. Please contact Paula Miller at 568-6495 with questions.

REQUEST OF CERTIFICATE OF COVERAGE

Date of Request:

Name of Person Submitting:

E-mail of Person Submitting:

MSC of Person Submitting:

Phone of person submitting:

Certificate Issued to (Name of Company/Medical Facility - Note: This section cannot be made out to JMU):

Attention:

Address Issued to:

City, State, Zip to:

 

Coverage Period:

Purpose: