Unformatted text preview: University of Central Florida
4000 Central Florida Blvd.
Communications Building ยท Room 121
Orlando, FL 32816-3120
(407) 823-4285 โข [email protected] Request Form for Certificate of Insurance
Fill this form out completely and EMAIL it to Lisa Cook. Please allow ample time to process the request โ at least 2 business days.
Once I have approved your request, I email our agent the form and she emails back a certificate.
I forward the certificate to you via email.
It is your responsibility to get copies of the certificates to the correct recipients on your project. THIS FORM MUST BE EMAILED TO ME. NO HANDWRITTEN REQUEST FORMS WILL BE ACCEPTED. Please provide the info for the Person/company asking for proof of insurance:
Company โโโโโ Mr./Ms. โโโโโ Address โโโโโ City, State, Zip โโโโโ Phone number โโโโโ Fax number โโโโโ Website address โโโโโ Email of contact person โโโโโ Director of film: โโโโโ
Name of Project: โโโโโ Phone number of Student Director: โโโโโ Email of Student Director: โโโโโ Name of Student Producer: โโโโโ Phone number of Student Producer: โโโโโ What class is this film for?: โโโโโ Who is the faculty member teaching this class? โโโโโ Location(s): โโโโโ Date(s) of shoot(s): โโโโโ Hours of shoot (list hours for each day you will be shooting, including setยญup and wrap time): โโโโโ
Describe nature of shoot โ any stunts, effects, minors, animals, guns, pyro? โโโโโ
How many TOTAL cast and crew expected?: โโโโโ
How many TOTAL cars, trucks, vehicles expected?: โโโโโ ...
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- Summer '10
- Orlando, Phone Number