Minnesota Counties Intergovernmental Trust   
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Request for
   Certificate
       
Contact Name: Date of Request: 8/22/2017
Member:
Account Number:    
E-Mail Phone #:
      (xxx)xxx-xxxx

Certificate holder information:  
Name:
Contact Person:
Address:
     
Type of Coverage:  
General Liability Automobile          
Property/Inland Marine Worker's Compensation         
Public Officials Liability    
       
Description for Certificate:
  Include dates / location / values / serial numbers, if applicable
 
COMMENTS:

I would like a copy of the submitted form.

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