ࡱ> QSP  bjbjVV 4><<44wwwww84v(fhhhhhh$] "wwwLwwffJ062FbR0j,# ##w #4 =: Risk Management Department Request for Certificate of Insurance From Others Name of Person and ӣ Department Requesting Certificate of Insurance: Name: Department: Phone Number: Fax Number: Insurance Requirements: (Check all that apply) Automobile Liability: $ Professional Liability: $ General Liability: $ Workers Compensation: $ Property Insurance: $ Other: $ Explain: Entity Requesting a Copy of ӣs Certificate of Insurance: (A complete mailing address must be furnished) Name: Company: Address: City/State/Zip: Phone Number: Fax Number: Activity to take place, or relationship to company that is requesting Certificate of Insurance: The Purchasing department and the Office of the General Counsel have reviewed contract/Agreement/Permit. A copy of Supporting documentation is attached Yes____ Yes____ No____ No____ NOTE: This completed form must be received by the Risk Management Department least three (3) working days prior to the activity or event.       HYPERLINK "http://www.yu.edu" \o "ӣ"  INCLUDEPICTURE "http://yu.edu/_global/logo/headerSmNew.jpg" \* MERGEFORMATINET  500 W. 185th Street, Belfer Hall 1016 Tel: 212-960-5400 Ext. 6739 Email:riskmgmt@yu.edu LMNOPѹwbJb3,hovhc]5B*CJOJQJ^JaJph33/hovhc]5B*CJOJQJ\^JaJph33)hovhc]B*CJOJQJ^JaJph33)hovhmB*CJOJQJ^JaJph33)hovh bB*CJOJQJ^JaJph33/hovhc]5B*CJOJQJ\^JaJph33/hovhU`5B*CJOJQJ\^JaJph33/hovhc]5B*CJ'OJQJ\^JaJ'ph33,hovhc]5B*CJ/OJQJ^JaJ/ph33 LMNOPrdddV $7$8$H$Ifgdov $7$8$H$Ifgdovikd$IfK$L$l%% t0644 laytov$$7$8$H$Ifa$gdovK$$$7$8$H$Ifa$gdovf{kd$IfK$L$l\t%t <  t644 laytov $7$8$H$Ifgdov$7$8$H$IfgdovK$  " $ % < @ R U j n Կ鿨xԐxxcN)hovhc]B* CJOJQJ^JaJph)hovh bB* CJOJQJ^JaJph/hovh b5B*CJOJQJ\^JaJph33/hovhc]5B*CJOJQJ\^JaJph33,hovhc]5B*CJOJQJ^JaJph33)hovhc]B*CJOJQJ^JaJph33)hovh bB*CJOJQJ^JaJph33,hovh b5B*CJOJQJ^JaJph33 uuf$7$8$H$IfgdovK$ $7$8$H$Ifgdov{kd+$IfK$L$l\t%t <  t644 laytov # % = ? $7$8$H$IfgdovK$ikd$IfK$L$l%% t0%644 laytov? @ S U k m tttt$7$8$H$IfgdovK${kdd$IfK$L$l\ % $   t%644 laytovm n tttt$7$8$H$IfgdovK${kd$IfK$L$l\ % $   t%644 laytov uf$7$8$H$IfgdovK$ $7$8$H$Ifgdov{kd$IfK$L$l\ % $   t%644 laytov    * + 5 6 G H W X d e g h ѽѥѐ~lllllWBB)hovhmB*CJOJQJ^JaJph33)hovh bB*CJOJQJ^JaJph33#hovhc]5CJOJQJ^JaJ#hovh b5CJOJQJ^JaJ)hovhc]B*CJOJQJ^JaJph33/hovh b5B*CJOJQJ\^JaJph33&hovh b5CJOJQJ\^JaJ/hovhc]5B*CJOJQJ\^JaJph33,hovh bB* CJOJQJ\^JaJph  j\\N $7$8$H$Ifgdov $7$8$H$IfgdovBkd$IfK$L$l%% t%644 laytov$7$8$H$IfgdovK$Bkde$IfK$L$l%% t%644 laytov    xx$7$8$H$IfgdovK$ $7$8$H$Ifgdovikd$IfK$L$l%% t0644 laytov ! * + , 5 6 DUkd$IfK$L$l0(%( t644 laytov$7$8$H$IfgdovK$Ukd$IfK$L$l0(%( t644 laytov6 7 G H I W X d DUkd$IfK$L$l0(%( t644 laytov$7$8$H$IfgdovK$Ukd$IfK$L$l0(%( t644 laytovd e f g h tffXX $7$8$H$Ifgdov $7$8$H$Ifgdov{kdm$IfK$L$l\(%(   t644 laytov$7$8$H$IfgdovK$ ikd$IfK$L$l%% t0644 laytov$7$8$H$IfgdovK$ikd&$IfK$L$l%% t0644 laytov 9 h p q xxgTFF $7$8$H$Ifgdov & F$7$8$H$IfgdovK$ & F$7$8$H$Ifgdov $7$8$H$IfgdovikdP $IfK$L$l%% t0644 laytov$7$8$H$IfgdovK$ 7     ꩏w`F/,hovh b5B*CJOJQJ^JaJph332hovhm5>*B*CJOJQJ\^JaJph33,hovhc]5B*CJOJQJ^JaJph33/hovhc]5B*CJOJQJ\^JaJph332hovhc]5>*B*CJOJQJ\^JaJph33,hovhc]5B*CJOJQJ^JaJph33)hovh1B*CJOJQJ^JaJph33)hovh bB*CJOJQJ^JaJph33)hovhc]B*CJOJQJ^JaJph33 q y  yk` $Ifgdl>K$ $7$8$H$Ifgdovhkd $IfK$L$lF %Y t%6    44 laytov $7$8$H$Ifgdov$7$8$H$IfgdovK$     n` $7$8$H$IfgdovBkd $IfK$L$l%% t644 laytov $Ifgdl>K$BkdW $IfK$L$l%% t644 laytov      " # % & ' ( z$x]x^a$gd0 7$8$H$gdmhkd $$Ifld&& t0&644 laytov        ! " # $ % & ' ( ) ` a b ¾¾¾¾t\Qh/mhfCJaJ/h/mhf5>*B*CJ2OJQJ^JaJ2ph(jn hU`B* CJOJQJUaJphahU`B* CJOJQJaJpha(jhU`B* CJOJQJUaJphajhU`UhovhU`h;9h/mh;9CJaJjh/mh;9CJUaJh/mhc]CJaJ/hovhc]5B*CJOJQJ\^JaJph33         7$8$H$gdm$x]x^a$gd0           麥}rh/mhc]CJaJh;9hovhU`h/mhfCJaJ h/mhf5B*CJaJ ph(h/mhf5B*CJOJQJaJ ph,h/mhI5B*CJOJQJ^JaJ ph/h/mhf5B*CJH*OJQJ^JaJ ph,h/mhf5B*CJOJQJ^JaJ ph 21h:p/m/ =!"#$% ~$IfK$L$l!vh5%#v%:V l t065%ytov$IfK$L$l!vh5t5 55< #vt#v #v#v< :V l t65t5 55< / / ytov$IfK$L$l!vh5t5 55< #vt#v #v#v< :V l t65t5 55< / / ytov$IfK$L$l!vh5%#v%:V l t0%65%/ ytov$IfK$L$l!vh5 5$ 5 5#v #v$ #v #v:V l t%65 5$ 5 5/ / ytov$IfK$L$l!vh5 5$ 5 5#v #v$ #v #v:V l t%65 5$ 5 5/ / ytov$IfK$L$l!vh5 5$ 5 5#v #v$ #v #v:V l t%65 5$ 5 5/ / ytovY$IfK$L$l!vh5%#v%:V l t%65%/ ytovY$IfK$L$l!vh5%#v%:V l t%65%/ ytov$IfK$L$l!vh5%#v%:V l t065%/ ytovo$IfK$L$l!vh5(5#v(#v:V l t65(5/ ytovo$IfK$L$l!vh5(5#v(#v:V l t65(5/ ytovo$IfK$L$l!vh5(5#v(#v:V l t65(5/ ytovo$IfK$L$l!vh5(5#v(#v:V l t65(5/ ytov$IfK$L$l!vh5(5 55 #v(#v #v#v :V l t65(5 55 / / / ytov$IfK$L$l!vh5%#v%:V l t065%/ / ytov$IfK$L$l!vh5%#v%:V l t065%/ ytov$IfK$L$l!vh5%#v%:V l t065%/ ytovw$IfK$L$l!vh555Y#v#v#vY:V l t%6555YytovK$IfK$L$l!vh5%#v%:V l t65%ytovK$IfK$L$l!vh5%#v%:V l t65%ytov{$$If!vh5&#v&:V l t0&65&ytovDd)  s XAheaderSmNewlogoimage"0*"Yeshiva University"RN_"NQk+v FN_"NQk+vJFIFddDucky<Adobed       6!1AQ"2aqBR#3rS4!1QAq"aB2R ?W Ju]ʭD%g$71 誋!VĜ(ZTMQ$i&vC@LADmJM1`)o궯 HaRTHd:&wj+tq =Dc;((d#MP`JHnEjkjCddNN (̆uDB^FSi*<}mSVO"3VpP @(P @(P @(,gjjLa#6NB!QEZ+mjݞ0=s3u ># ˒ Z'@!}r!V+Uj㏩?)dd2Bomn _5VJ\ťo/ٜ+#XMAֲe|pοȗ͸ )NY55OM,?~㏡iqǙ@.@r|t6yF*9r@W$?dG4-ZkE*$"0FpqFH}T.Zu(LH @(P @(P @(RHəZǗ#c(t@䪝 < vg'É<a*6:qןm.4!<ܨ6FsQ]ET-Urtma-ժ.)A1qs#4GnB}-U]=uiqjiIRryipn$#L2ɻ *Ui\$zGccۮ6o d!m"l%Tu`zKa&Df7U"EV̑ToWv٭t7d)~@!)]ʨʪx @ hUu6KJ*Uihڏ iFq4āU>j6!r.V=4Tm?/7>,=2 |ӱlmɌ7kCE-A|.ޛۮX63(,$MFUxUIElwxȯwoj>9从L(A]_ڔ5o'^&{&fF0mIGB?"n%TwjĿQm5w5= d8^)-Mơ;pq$B<5J]Т488\ '(HtBOԩue(ua@(?!s:Z-IRjʃÓapqy8"ϛ.lGrnuc5rhDT6"Y>jiB>ƚ'̾t.1]fXRPHWAMw&$+]SՖ^/]y{) 3ܑyQ>PQq6 ̄ҿ.,ID`:7OTЌ3H7?e/Ɔ߽vYDIufN]U%sj-"PV6j_ #-/2Z D…Ȓ K-CaZ}[cv$Os12= 28I1\@&uT I{na'[MĮ}gJgMaђRv>[m lߥa5e0;7[ @|ZWq1ceƛ3%_ l9 VO>E+`kۙ-Z`F)8Vljhel>q77b8$V&Bqp5V-uizwzwi3;5בpզx%؛b$ WZ9i#'u?՗l\i >+ѳ;,ᰭzƲѴҞ:44Tާ:c%3𥴳-㹽@ƥJ]$q\#sB'Cز춨- l^Vsӵٲ,ޕ7α7tv,2It+2L]B]5;'EQiv*?%77ǽ3- o:VU)fy1sd6g>1tZp 0_7p~:UM5 Oms1x0BY(6SkI@r훊断?wsmce_ h.2Hm[@EM?O5sK]NU&K&Ao~A%"_Zڔ(FVɎpP @( $_(n'vBUE&]UӉݩA;a"ʹPΟ;I%;#5a?"[a=UNtE]Q[4QF +cێ|%y4jKer mH%PHmZ"!']؂؊m [ҥ{ysn|o0[ rERmUrKDK֚WAE,ѫ@(P @(P }!zuذDΒЗ3\`?/[G\!-Rk.sԻ..a濭?PK!֧6 _rels/.relsj0 }Q%v/C/}(h"O = C?hv=Ʌ%[xp{۵_Pѣ<1H0ORBdJE4b$q_6LR7`0̞O,En7Lib/SeеPK!kytheme/theme/themeManager.xml M @}w7c(EbˮCAǠҟ7՛K Y, e.|,H,lxɴIsQ}#Ր ֵ+!,^$j=GW)E+& 8PK!Ptheme/theme/theme1.xmlYOo6w toc'vuر-MniP@I}úama[إ4:lЯGRX^6؊>$ !)O^rC$y@/yH*񄴽)޵߻UDb`}"qۋJחX^)I`nEp)liV[]1M<OP6r=zgbIguSebORD۫qu gZo~ٺlAplxpT0+[}`jzAV2Fi@qv֬5\|ʜ̭NleXdsjcs7f W+Ն7`g ȘJj|h(KD- dXiJ؇(x$( :;˹! I_TS 1?E??ZBΪmU/?~xY'y5g&΋/ɋ>GMGeD3Vq%'#q$8K)fw9:ĵ x}rxwr:\TZaG*y8IjbRc|XŻǿI u3KGnD1NIBs RuK>V.EL+M2#'fi ~V vl{u8zH *:(W☕ ~JTe\O*tHGHY}KNP*ݾ˦TѼ9/#A7qZ$*c?qUnwN%Oi4 =3ڗP 1Pm \\9Mؓ2aD];Yt\[x]}Wr|]g- eW )6-rCSj id DЇAΜIqbJ#x꺃 6k#ASh&ʌt(Q%p%m&]caSl=X\P1Mh9MVdDAaVB[݈fJíP|8 քAV^f Hn- "d>znNJ ة>b&2vKyϼD:,AGm\nziÙ.uχYC6OMf3or$5NHT[XF64T,ќM0E)`#5XY`פ;%1U٥m;R>QD DcpU'&LE/pm%]8firS4d 7y\`JnίI R3U~7+׸#m qBiDi*L69mY&iHE=(K&N!V.KeLDĕ{D vEꦚdeNƟe(MN9ߜR6&3(a/DUz<{ˊYȳV)9Z[4^n5!J?Q3eBoCM m<.vpIYfZY_p[=al-Y}Nc͙ŋ4vfavl'SA8|*u{-ߟ0%M07%<ҍPK! ѐ'theme/theme/_rels/themeManager.xml.relsM 0wooӺ&݈Э5 6?$Q ,.aic21h:qm@RN;d`o7gK(M&$R(.1r'JЊT8V"AȻHu}|$b{P8g/]QAsم(#L[PK-![Content_Types].xmlPK-!֧6 +_rels/.relsPK-!kytheme/theme/themeManager.xmlPK-!Ptheme/theme/theme1.xmlPK-! ѐ' theme/theme/_rels/themeManager.xml.relsPK] >      ? m  6 d q     FGXCt8@0(  B S  ? "#%& "#%&LNP  $$%%!!,,77IIfg7&KLNO "#%&l?Dh hh^h`hH.h 88^8`hH.h L^`LhH.h   ^ `hH.h   ^ `hH.h xLx^x`LhH.h HH^H`hH.h ^`hH.h L^`LhH.l?         )(n21h n%v%VQ29e4;9_8SgYh[c]U`]esfSh/m*nXv(jov8:& )JfQDQ|m1I0l> b@ 5 @Unknown G* Times New Roman5Symbol3. * ArialINMonotype Corsiva=Times-Bold7.  Verdana KLJDJD+TimesNewRoman,BoldItalicTimes New Roman5. *aTahomaA BCambria Math"h{F{F#F~~!r4d 3qHX ?!xxRisk Management Department Ellowine Dodd Ellowine Dodd Risk Management Department Title ,8@L     l x    _PID_HLINKSEktContentID64EktContentLanguageEktFolderId64 EktQuickLinkEktContentTypeEktContentSubType EktFolderName EktCmsPath EktGoLiveDate EktExpiryType EktDateCreatedEktDateModifiedEktTaxCategoryEktDisabledTaxCategory EktCmsSizeEktSearchableEktEDescription EktInPermekttaxonomyenabled EktAddressEktRSVPA`57http://www.yu.edu/ `" E DownloadAsset.aspx?id=8800e@ NZG@P5'G@'G\Summary &lt;p&gt;Risk Management Department Request for Certificate of Insurance From Others Name of Person and Yeshiva University Department Requesting Certificate of Insurance: Name: Department: Phone Number: Fax Number: Insurance Requirements: (Checkcate of Insurance From Others Name of Person and Yeshiva University Department Requesting Certificate of Insurance: Name: Department: Phone Number: Fax Number: Insurance Requirements: (Check all that apply) Automobile Liability: $ &lt;/p&gt;T&lt;p&gt;Risk Management Department Request for Certificate of Insurance From Others Name of Person and Yeshiva University Department Requesting Certificate of Insurance: Name: Department: Phone Number: Fax Number: Insurance Requirements: (Check all that apply) Automobile Liability: $ &lt;/p&gt;EktTaxCategoryEktDisabledTaxCategor all that apply) Automobile Liability: $ &lt;/p&gt;T&lt;p&gt;Risk Management Department Request for Certificate of Insurance From Others Name of Person and Yeshiva University Department Requesting Certificate of Insurance: Name: Department: Phone Number: Fax Number: Insurance Requirements: (Check all thyat apply) Automobile Liability: $ &lt;/p&gt;՜.+,D՜.+,X hp   ӣ Risk Management Department Title 8@ _PID_HLINKSA`57http://www.yu.edu/  !"#$%&'()*+,-/0123456789:;<=>?ABCDEFGRU@Root Entry FkLTData  `1Table.#WordDocument4>SummaryInformation(DocumentSummaryInformation8  CompObjy +  !"#$%&'()*@,-./0123456789:;<=>?KABCDEFGHIJLMN  F'Microsoft Office Word 97-2003 Document MSWordDocWord.Document.89qOh+'0h8 PD X@@Ң>@2@2~+request_for_coi_from_others_02_15_2011.docInternal AdministratorInternal AdministratorT&lt;p&gt;Risk Management Department Request for Certifi՜.+,D՜.+,x4  (