Housatonic Valley Insurance Agency Inc. - Insurance New Milford CT

6 Main Street

New Milford, CT 06776

NO Telemarketing or Soliciting

(860) 354-5551

Request A Certificate Of Insurance

Great News! You can request a certificate of insurance from us any time of day or night using this form.

Please provide sufficient information to insure proper certificate completion & delivery.

Once you've submitted your certificate request, it will be forwarded to us immediately for processing.

Your certificate of insurance will be available within 24 business hours.

Individual or Business Name (insured at HVI):

Individual Name or Business Name requesting proof of insurance from HVI client. This is who will be listed as the Certificate Holder (NOT the HVI insured):

Street Address, City, State, Zip of the requestor who's listed above (NOT the HVI insured):

Is there's a specific policy period you need listed on the certificate?:

How would you like to receive the certificate?

Mail Fax Email Pick up at HVI office

Please provide your fax number, address, or email address if you chose that selection above:

Please provide information about what the certificate should include:

Job or Loan Number that should be referenced (if applicable):

Specific property address that needs to be referenced? (if applicable):

Additional Insured clause that needs to be added (if applicable):

Any other special wording required (if applicable):

Please indicate any other special instructions (if applicable):

* Required