Certificate of Insurance (COI) Request Form

In order to expedite your request to receive a certificate of insurance (COI), please note the following: All contracts and agreements should be in the name of your chapter (e.g. “Omega Omega Chapter of Pi Kappa Alpha” or “Omega Omega Chapter”); listing “Pi Kappa Alpha” in an agreement implies the International Fraternity, which is not a party to such agreements.

All requests for a COI should be accompanied by documentation (contracts, agreements, etc.) detailing the specific insurance requirements for the chapter. Chapters must have a zero balance in order to receive a COI. You may still request a COI with a balance but must confirm that the balance is paid before a COI can be issued.

Chapters should allow five business days for a COI to be processed. In order to expedite your request, please ensure all information is complete.

Your Contact Information

Name: *

Chapter: *

Email Address: *

Phone Number: *

Before completing your COI request, please select the current financial status of your chapter. *

My chapter has a $0 balance

My chapter is up to date on its payment plan

My chapter does not have a $0 balance nor is up to date on its payment plan

Event Details

Name of Event *

Description of Event *

Requesting Party

Is this a requirement of: *

University

IFC

3rd Party Vendor

Other (please describe) Other (please describe)

Representative of Requesting Party (this cannot be a chapter member): *

Email Address of Requesting Party (this cannot be a chapter member): *

Phone Number of Requesting Party (this cannot be a chapter member): *

Special Requests: *

None

Additional Insured (chapter acknowledges $250 fee for event)

Other (please describe) Other (please describe)

Additional Requirements

Please attach any and all formal document(s) which detail the insurance coverage requirements.

Examples: recognition statement, student organizational guidelines, event requirements, event contract/agreements, etc.

Note: The complete document should be attached.

*

Additional Document

Please check the below box to acknowledge that you understand certificates of insurance can take up to five business days to process. *

I understand

Please check the below box to acknowledge that the requesting party you submitted is not an undergraduate member. *

I understand

In order to receive a certificate of insurance (COI), your chapter is required to have a zero balance with the International Fraternity and provide documentation of the requesting party's insurance requirements. These requirements could include but are not limited to insurance limits, additional insured(s), certificate holder(s), etc. Submitting your COI request without appropriate documentation could result in delayed processing.

By pressing 'Submit' below you are acknowledging that certificates can take up to five days for processing.

In order to receive a certificate of insurance (COI) your chapter is required to have a zero balance with the International Fraternity. Please contact finance@pikes.org if you have any questions about your outstanding balance.

Contact insurance@pikes.org with any questions about Certificate of Insurance (COI) Request Form.