(Note: Certificates are only issued through June 30, 2020 due to possible rate changes past this date. Please resubmit a new Certificate of Coverage request for dates beyond this date around the beginning of May 2019, at which point  we will hopefully know any new coverage limits, if there are changes in any of them.)

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.


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):


Address Issued to:

City, State, Zip to:


Coverage Period:


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