Workers Compensation and Auto Liability Insurance 

Requests for certificates of insurance for workers compensation and auto liability must be requested from the Nebraska State Risk Management Office. 

Certificate of Insurance Request Form

The form below should be used by the State Colleges to request certificates of insurance for property and liability insurance required by third parties. Certificates should be requested at least three (3) days in advance of an event. Questions regarding Certificates of Insurance should be directed to Angela Melton, Vice Chancellor for Student Affairs & Risk Management at

Date of Request

Date Needed By:

Start Date of Event, Activity, or Contract

End Date of Event, Activity, or Contract

Requestor Information

Certificate Holder Information - Exact name as it should appear on the certificate.


What type of insurance policy/coverage is needed? (Select all that apply)

Will this certificate need to be sent again when the selected insurance policy renews? Most insurance policies renew on July 1.