Additional Insured Request Form

Additional Insured Request Form

Additional Insured may be added to our policy. Such Additional Insured may be your landlord, college, university and/or proprietor from whom the chapter may be renting property for a special event.

Upon review and approval of the Additional Insured request by Delta Upsilon Fraternity and the insurance carrier, a certificate of insurance will be issued by Willis, with the original forwarded to the Additional Insured and a copy to the International Headquarters.
 
 
Chapter*
Chapter Address*
Your Name*
Your Address*
City*
State/Province*
Postal Code*
Phone*
Email*
Fax
Additional Insured's Name*
Address*
City*
State/Province*
Postal Code*
Phone*
Email*
Date of Event*
Time of Event*
Event Address*
Limits Requested by Additional Insured*
Event Description*
Are Certificates of Insurance obtained from vendors?
Liquor Legal Liability* Yes
No
Not Applicable
General Liability* Yes
No
Not Applicable
Has vendor(s) provided proof of liquor license and temporary license to see on premises?* Yes
No
Not Applicable
Is the Fraternity named as an additional insured on all certificates from vendors?* Yes
No
Not Applicable
Have applicable permits and permission been obtained from authorities?
College/University* Yes
No
Not Applicable
Fund Raiser* Yes
No
Not Applicable
Has any written contract or agreement been signed for any part of this special event?* Yes
No
Not Applicable
Have you received any correspondence requesting proof of insurance for the event?* Yes
No
Not Applicable

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