Virginia Administrative Code › Title 9 - ENVIRONMENT › Agency 20 - VIRGINIA WASTE MANAGEMENT BOARD › Chapter 170 - TRANSPORTATION OF SOLID AND MEDICAL WASTES ON STATE WATERS › Part VI - Financial Responsibility Requirements for Vessels Transporting Solid Wastes or Regulated Medical Wastes › Section 9VAC20-170-400:5 - APPENDIX V

Current through Register Vol. 40, No. 24, July 15, 2024
(NOTE: Instructions in brackets are to be replaced with
					 the relevant information and the brackets deleted.)
CERTIFICATE OF INSURANCE FOR LIABILITY COVERAGE.
1. [Name of Insurer], (the "Insurer"), of
				  [address of Insurer] hereby certifies that it has issued liability insurance
				  covering bodily injury and property damage to [name of insured], (the
				  "insured"), of [address of insured] in connection with the insured's obligation
				  to demonstrate financial responsibility under
				  9VAC20-170-330 of the
				  Transportation of Solid and Medical Waste on State Waters Regulations. The
				  coverage applies to the vessels listed on the attached Schedule A for sudden
				  accidental occurrences and/or nonsudden accidental occurrences. The limits of
				  liability are [insert the dollar amount of the "each occurrence" and "annual
				  aggregate" limits of the Insurer's liability], exclusive of legal defense
				  costs. The coverage is provided under policy number ______, issued on [date].
				  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.
(b) The Insurer is liable for the payment of
				  amounts within any deductible applicable to the policy, 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 as specified in
				  9VAC20-170-330.
(c) Whenever requested by the Director of the
				  Department of Environmental Quality, Commonwealth of Virginia or a Regional
				  Administrator of the U.S. Environmental Protection Agency (EPA), the Insurer
				  agrees to furnish to the director or Regional Administrator a signed duplicate
				  original of the policy and all endorsements.
(d) Cancellation of the insurance, whether by
				  the insurer, the insured, a parent corporation providing insurance coverage for
				  its subsidiary, or by a firm having an insurable interest in and obtaining
				  liability insurance on behalf of the owner or operator of a covered vessel,
				  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 Department of
				  Environmental Quality, Commonwealth of Virginia.
(e) Any other termination of the insurance
				  will be effective only upon written notice and only after the expiration of
				  thirty (30) days after a copy of such written notice is received by the
				  Department of Environmental Quality, Commonwealth of Virginia.
I hereby certify that the wording of this instrument is
					 identical to the wording specified in the relevant regulations of the
					 Department of Environmental Quality, Commonwealth of Virginia, and that the
					 Insurer is licensed to transact the business of insurance, or eligible to
					 provide insurance as an excess or surplus lines insurer, in one or more
					 States.
[Signature of authorized representative of Insurer]
[Type name]
[Title], Authorized Representative of [name of
					 Insurer]
[Address of Representative]
SCHEDULE A
IDENTIFICATION OF COVERED VESSELS
Insurance Policy [insert policy number] is applicable to
					 the following vessels:
Vessel Name Gross tons Owner Operator