Virginia Administrative Code › Title 9 - ENVIRONMENT › Agency 25 - STATE WATER CONTROL BOARD › Chapter 590 - PETROLEUM UNDERGROUND STORAGE TANK FINANCIAL RESPONSIBILITY REQUIREMENTS › Section 9VAC25-590-260:4 - APPENDIX IV. CERTIFICATE OF INSURANCE

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 insurer:
Address of insurer:
Name of insured:
Address of insured:
Certification:
1.
				[Name of insurer], The insurer, as identified above, hereby certifies that it
				has issued liability insurance covering 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).
[List the number of tanks at each facility and the name(s)
				  and address(es) of the facility(ies) where the tanks are located. If more than
				  one instrument is used to assure different tanks at any one facility, for each
				  tank covered by this instrument, list the tank identification number provided
				  in the notification submitted pursuant to
				  9VAC25-590-70 (Underground Storage
				  Tanks; Technical Standards and Corrective Action Requirements), and the name
				  and address of the facility.]
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" or "accidental
				  releases"; in accordance with and subject to the limits of liability,
				  exclusions, conditions, and other terms of the policy; [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 are [insert the dollar amount of the
				  corrective action "each occurrence" and third party "each occurrence" and
				  "annual aggregate" limits of the insurer's liability; 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 policy.
				  This coverage is provided under [policy number]. The effective date of said
				  policy is [date].
2. The
				insurer further certifies the following with respect to the insurance described
				in paragraph 1:
a. Bankruptcy or insolvency
				of the insured shall not relieve the insurer of its obligations under the
				policy to which this certificate applies.
b. The insurer 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 insured for any such payment made by the insurer. 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 insurer agrees to furnish to the State Water Control Board a
				signed duplicate original of the policy and all endorsements.
d. Cancellation or any other termination of
				the insurance by the insurer, except for nonpayment of premium or
				misrepresentation by the insured, 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 insured and the State Water Control Board. Cancellation for
				nonpayment of premium or misrepresentation by the insured 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 insured and the State
				Water Control Board.
[Insert for claims-made policies]
e. The insurance covers claims otherwise
				covered by the policy that are reported to the insurer within six months of the
				effective date of cancellation or nonrenewal of the policy except where the new
				or renewed policy has the same retroactive date or a retroactive date earlier
				than that of the prior policy, and which arise out of any covered occurrence
				that commenced after the policy retroactive date, if applicable, and prior to
				such policy 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 policy.
I hereby certify that the wording of this instrument is
				  identical to the wording in APPENDIX IV of 9VAC25-590 and that the insurer is
				  licensed to transact the business of insurance, or eligible to provide
				  insurance as an excess or approved surplus lines insurer, in the Commonwealth
				  of Virginia.
[Signature of authorized representative of insurer]
[Type name] [Title], authorized representative of name of
				  insurer
[Address of representative]