CVMIC March 6, 2021

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 Diane Rediske, if you have any problems or questions regarding the certification process.
Village/City:  * Date Needed By:      *
Requested By:  * Phone:  *
Email Address:  * Fax:
Certificate Holder:  * Contact:  *
Address:  * City:  *
State:  * Zip Code:  *
Fax to Certificate Holder: Fax Number:
Complete Description:
CVMIC To Issue Certificates
General Liability Limit:
Auto Liability Limit:
Worker's Compensation
Coverage A Limits: Statutory
Coverage B Limits:  100/500/100
Gallagher To Issue Certificates
Excess Liability Limit:
APD Protection, Loss Payable Clause: yes
Boiler & Machinery, Loss Payable Clause: yes
Other Coverage: Limit:
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.

Office Use Only:

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