Certificate of Coverage Request Form - Adobe PDF format

Certificate of Coverage Request Form - Microsoft Word 2003 format

1. Complete the Certificate of Coverage Request Form by selecting the appropriate version of the form above.
2. Be sure to include the following important information: reason(s) for the certificate; name/address of any additional insured or loss payee; date of the transaction; and the year/make/model/VIN/serial number and value of the property today if the certificate is in regard to a specific vehicle or piece of equipment.
3. If the certificate is being issued as part of a contract or written agreement, we will need to review the contract or agreement prior to issuing the certificate.
4. Print the form and fax it to (217) 443-0927, or
5. Mail it to:
IMLRMA
c/o CCMSI
2 East Main Street
Danville, IL 61832
6. If you have problems with or questions about the form, please contact us at: (800) 252-5051.
7. After we issue the certificate (via fax or mail), we will mail the original to you and keep a copy in our files.

A Certificate of Coverage is only good for the coverage dates listed, so generally, your certificates will expire each December 31st. Please notify us each year if there are any certificates that you would like updated and reissued.