Virginia Administrative Code › Title 9 - ENVIRONMENT › Agency 25 - STATE WATER CONTROL BOARD › Chapter 590 - PETROLEUM UNDERGROUND STORAGE TANK FINANCIAL RESPONSIBILITY REQUIREMENTS › Section 9VAC25-590-260:12 - APPENDIX XII. CERTIFICATE OF GROUP SELF-INSURANCE POOL MEMBERSHIP

Current through Register Vol. 40, No. 24, July 15, 2024
[NOTE: The instructions in brackets are to be replaced by the
				  relevant information and the brackets deleted.]
Name: [name of each covered location]
Address: [address of each covered location]
Policy number:
Endorsement (if applicable):
Period of coverage: [current policy period]
Name of Group self-insurance pool:
Address of Group self-insurance pool:
Name of Member:
Address of Member:
Certification:
1.
				[Name of Group Self-Insurance Pool], the group self-insurance pool, "Pool," as
				identified above, hereby certifies that it has entered into a Membership
				Agreement (Agreement) with the member to provide liability coverage for the
				following underground storage tank(s) in connection with the insured's
				obligation to demonstrate financial responsibility under the Virginia Petroleum
				Underground Storage Tank Financial Requirements Regulation (9VAC25-590) for
				[insert: "taking corrective action" and/or "compensating third parties for
				bodily injury and property damage"] caused by either sudden accidental releases
				or nonsudden accidental releases; in accordance with and subject to the limits
				of liability, exclusions, conditions, and other terms of the Pool Plan (Plan)
				and Agreement; [if coverage is different for different tanks or locations,
				indicate the type of coverage applicable to each tank or location] arising from
				operating the underground storage tank(s) identified above.
The limits of liability of the Pool are [insert the dollar
				  amount] corrective action per occurrence and [insert dollar amount] third party
				  liability per occurrence and [insert dollar amount] annual aggregate. [If the
				  amount of coverage is different for different types of coverage or for
				  different underground storage tanks or locations, indicate the amount of
				  coverage for each type of coverage and/or for each underground storage tank or
				  location], exclusive of legal defense costs, which are subject to a separate
				  limit under the Plan or Agreement. This coverage is provided under the Plan
				  dated [insert date] and the Agreement entered into between [name of member] and
				  [name of Pool]. The effective date of said Agreement is [date].
2. The Pool further certifies the
				following with respect to the coverage described in paragraph 1:
a. Bankruptcy or insolvency of the member
				shall not relieve the Pool of its obligations under the policy to which this
				certificate applies.
b. The Pool is
				liable for the payment of amounts within any deductible applicable to the
				policy to the provider of corrective action or a damaged third party, with a
				right of reimbursement by the member for any such payment made by the Pool.
				This provision does not apply with respect to that amount of any deductible for
				which coverage is demonstrated under another mechanism or combination of
				mechanisms as specified in
				9VAC25-590-60 through
				9VAC25-590-110.
c. Whenever requested by the State Water
				Control Board, the Pool agrees to furnish to the State Water Control Board a
				signed duplicate original of the Agreement and Plan and all
				endorsements.
d. Cancellation or
				any other termination of the coverage by the Pool, except for nonpayment of
				premium or misrepresentation by the member, will be effective only upon written
				notice and only after the expiration of 60 days after a copy of such written
				notice is received by the member and the State Water Control Board.
				Cancellation for nonpayment of premium or misrepresentation by the member will
				be effective only upon written notice and only after expiration of a minimum of
				15 days after a copy of such written notice is received by the member and the
				State Water Control Board.
e. The
				Pool covers claims otherwise covered by the Agreement and Plan that are
				reported to the Pool within six months of the effective date of cancellation or
				nonrenewal of the Agreement except where the new or renewed Agreement has the
				same retroactive date or a retroactive date earlier than that of the prior
				Agreement and which arise out of any covered occurrence that commenced after
				the policy retroactive date, if applicable, and prior to such Agreement renewal
				or termination date. Claims reported during such extended reporting period are
				subject to the terms, conditions, limits, including limits of liability, and
				exclusions of the Agreement and Plan.
I hereby certify that the wording of this instrument is
				  identical to the wording in APPENDIX XII of 9VAC25-590 and that the Pool is
				  licensed by the Commonwealth of Virginia's State Corporation Commission
				  pursuant to 14VAC5-380.
[Signature of Authorized Representative of Pool]
[Type name], Authorized Representative of [name of
				  Pool]
[Address of representative]