Virginia Administrative Code › Title 9 - ENVIRONMENT › Agency 25 - STATE WATER CONTROL BOARD › Chapter 640 - ABOVEGROUND STORAGE TANK AND PIPELINE FACILITY FINANCIAL RESPONSIBILITY REQUIREMENTS › Section 9VAC25-640-250:8 - APPENDIX VIII. 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 aboveground storage tank(s) and/or pipelines in connection with the
				insured's obligation to demonstrate financial responsibility under the Virginia
				Petroleum Aboveground Storage Tank and Pipeline Facility Financial
				Responsibility Requirements Regulation (9VAC25-590-640) for [insert: "taking
				corrective action" and/or "compensating third parties for bodily injury and
				property damage containment and cleanup of discharges of oil"] 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, 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 of the Pool are [insert the dollar
				  amount] of the containment and cleanup "each occurrence" and "annual aggregate"
				  limits of the Group's liability; if the amount of coverage is different for
				  different types of coverage or for different aboveground storage tanks,
				  pipelines, or locations, indicate the amount of coverage for each type of
				  coverage and/or for each aboveground storage tank, pipeline or location 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,
				containment and cleanup 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
				9VAC25-640-70
				through
				9VAC25-640-120.
c. Whenever requested by the Department of
				Environmental Quality, the Pool agrees to furnish to the Department of
				Environmental Quality 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 Department of Environmental Quality.
				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
				Department of Environmental Quality.
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 9VAC25-640 and that the Pool is
				  licensed by the Commonwealth of Virginia's State Corporation Commission
				  pursuant to 14VAC5-3805.
[Signature of Authorized Representative of Pool]
[Type name], [Authorized Representative] of [name of
				  Pool]
[Address of representative]