Certificate Request

Our Certificate Request Form is in the process of being rebuilt. Until it is
available, please email your request to Diane Rediske (djr@cvmic.com)
with the information listed below:

- Village/City Name
- Requestor Phone Number
- Certificate Holder(Company)
- Certificate Holder Contact Name (if available)
- Certificate Holder Contact Email (if available)
- Certificate Holder Address, City, State, Zip
- Description
- Required Coverages (GL, APD, WC)
- Whether the Certificate Holder should be an Additional Insured
(For Additional Insureds, please attach the written contract/agreement)