CVMIC March 10, 2010
Activities and Information Training Loss Control Services Insurance Products Ask Ken,FAQ email CVMIC Certificate request

Back to Home Page
Email CVMIC
Certificate Request
Use the form below to request a Certificate of Insurance. Click Submit Request when you are finished. Fields marked with an * are required. Contact Mike DeMoss, mld@cvmic.com if you have any problems or questions regarding the certification process.
Village/City:  * Date Needed By:      *
Requested By:  * Phone:  *
Email Address:  * Fax:
 CERTIFICATE INFORMATION
Certificate Holder:  * Contact:  *
Address:  * City:  *
State:  * Zip Code:  *
Fax to Certificate Holder: Fax Number:
Complete Description:
 INSURANCE REQUIREMENTS
CVMIC To Issue Certificates
General Liability Limit:
Auto Liability Limit:
Worker's Compensation
Coverage A Limits: Statutory
Coverage B Limits:  100/500/100
Marsh To Issue Certificates
Excess Liability Limit:
APD Protection, Loss Payable Clause: yes  no
Boiler & Machinery, Loss Payable Clause: yes  no
Other Coverage: Limit:
 ENDORSEMENT INFORMATION
Additional Insured
Important - it is necessary to send a copy of insurance requirements and any attachments to add anyone as an additional insured.
Names/Special wording for endorsement:
Certificate should be renewed for future years.
Certificate should not be renewed for next year.

Top of Page
Company Background | Training | Loss Control Services | Insurance Products | FAQ