To access this form, the user must click the Select button beneath the associated image as shown below.
All starred (*) fields are required.
Defaults to your first and last name.
Requester’s Email cc:
If you would like to receive a copy of the certificate, please enter your email in the field.
Select your location from the drop down menu.
Select your department from the drop down menu.
Date Certificate needed (mm/dd/yyyy):
Click on the date box and select the date the certificate is needed.
Choose a certificate type:*
Click on drop down menu and select your certificate type.
Note: This drop down only applies to the ‘Professional Liability –Individual’ form and, at present, only appears when the location selected is UCLA Health System.
Certificate Holder Information
Complete Certificate Holder information sections. All starred* fields are required.
Send a copy to certificate holder:
If you select yes to this statement, then the certificate will be sent to the email address entered under the ‘Certificate Holder Contact Email:’ field. If you want to send additional copies of the certificate by email or fax, enter the contact info accordingly under the respective fields ‘Send a copy of the certificate to the following email(s)' or 'Send a copy of the certificate to the following fax(es)’. A certificate holder could be a person or entity who needs evidence of coverage.
Contract Expiration (mm/dd/yyyy):
Enter contract expiration date, mirroring the requested format.
Certificate Expiration (mm/dd/yyyy):
An autofill of the Certificate Expiration date field, in all certificate request forms, has been applied. The date will automatically be set to 7/1 of current calendar year if request is submitted prior to that date. If request date is after 7/1 of current calendar year then the autofill will set to 7/1 of next calendar year. The ability to edit the filed will remain in place should the user need to change date. However, it will not allow a user to exceed the default date set.
Renew this certificate?
Select whether or not you want the certificate to renew.
All starred* fields are required.
Specify contract/affiliation/service agreement name or number:*
Enter both the name and number, if you have both.
Please explain University purpose for which certificate is requested:*
Explain the purpose for which the certificate is requested.
Enter information in each field. *Designation is title (i.e. MD, NP, etc)
Clinical Activity Information
Complete all sections that apply.
If the required limits are different than t
he standard limits, please note the required limits in this section.
Attach Files and Relevant Information
Attach any necessary documents, and note any relevant information not requested elsewhere.
A maximum of four files total may
be attached, not exceeding five megabytes per file, 20 megabytes maximum.
Unsupportable file types include .wmv, .exe, .gif.
Note: this request will be automatically emailed to the Reviewer
& Approver for your location. If this certificate should be expedited please contact the Reviewer & Approver to be sure they
received your request. To find out whom the appropriate Reviewer & Approver
is for your department, please contact the Risk Services Representative or Team
for your campus and/or medical center.
Click the Submit button when the form is complete.