Certificate of Insurance Request – Internship/Experiential Programs

Complete this form when requesting evidence of insurance for a URI student to participate in an internship or clinical rotations at an off campus site or facility. The Certificate will provide coverage limits and effective dates evidencing General Liability Coverage and Professional Liability Coverage will be included for all clinical’s only. URI Certificates of Insurance (COI) will be processed within 3 business days and will be emailed directly to the University member requesting the certificate.

URI Certificate of Insurance Request - Internship/Experiential Programs

URI Department Name(Required)

Department Contact Person:(Required)

First Last

Department Email Address:(Required)

Name of Student:

First Last

Description of Internship:(Required)

Dates of Internship:(Required)

Begin Date:

End Date:

Certificate Holder Name & Address:(Required)

Name

This field is for validation purposes and should be left unchanged.