Virginia Administrative Code › Title 9 - ENVIRONMENT › Agency 25 - STATE WATER CONTROL BOARD › Chapter 640 - ABOVEGROUND STORAGE TANK AND PIPELINE FACILITY FINANCIAL RESPONSIBILITY REQUIREMENTS › Section 9VAC25-640-250:4 - 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 aboveground storage
				tank(s) and/or pipelines in connection with the insured's obligation to
				demonstrate financial responsibility under 9VAC25-640:
[List for each facility: the name and address of the facility
				  where tanks assured by this mechanism are located, either the registration
				  identification number assigned by the Department or the Oil Discharge
				  Contingency Plan facility identification number, and whether tanks are assured
				  by this mechanism. If more than one instrument is used to assure different
				  tanks at any one facility, list each tank assured by this mechanism.
List for each pipeline: the home office address and the names
				  of the cities and counties in the Commonwealth where the pipeline is
				  located.]
for containment and clean up of discharges of oil; 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,
				  pipelines or locations, indicate the type of coverage applicable to each tank,
				  pipeline or location] arising from operating the aboveground storage tank(s)
				  and/or pipelines identified above.
The limits of liability are [insert the dollar amount of the
				  containment and clean up "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 aboveground storage tanks or locations, indicate
				  the amount of coverage for each type of coverage and/or for each aboveground
				  storage tank, pipeline 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 containment and clean up 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
				  9VAC25-640-70
				  through
				  9VAC25-640-120.
c. Whenever requested by the
				Department of Environmental Quality, the Insurer agrees to furnish to the
				Department of Environmental Quality a signed duplicate original of the policy
				and all endorsements.
d.
				Cancellation or any other termination of the insurance by the Insurer, except
				for non-payment 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
				Department of Environmental Quality. Cancellation for non-payment 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 Department of Environmental Quality.
[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 9VAC25-640 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]