Multinational Clinical Trial Request Form

For your US produced Chubb Multinational program, use the below form to request a clinical trials certificate by providing the relevant information.

If you have any questions, please reach out to your Chubb service coordinator, or email: ClinicalTrialsCerts@Chubb.com

Insured Name

This field is mandatory

Country

This field is required

Protocol Number

This field is required

Trial Start Date

This field is required

Additional Insured / Sponsor Details

This field is required

Trial End Date

This field is required

Study Title

This field is required

Requestor Name

This field is required

Requestor Email

This is required field

Policy Number

This field is required

Name of Drug/Device

This field is required

Chubb Underwriter/Service Coordinator

This field is required

Number of Patient(s)

This field is required

Comments

This field is required

If you are a California resident, please read our Notice at Collection.