Washington Administrative Code › Title 173 - Ecology, Department of (See also Titles 197, 317, 372, and 508) › Chapter 173-360A - Underground storage tank regulations › Part 10 - FINANCIAL RESPONSIBILITY › Section 173-360A-1083 - Appendix D-Certificate of insurance

Current through Register Vol. 24-14, July 15, 2024
Name: [name of each covered location]
Address: [address of each covered location]
Policy Number:
Endorsement (if applicable):
Period of Coverage: [current policy period]
Policy Retroactive Date:
Name of [Insurer or Risk Retention Group]:
Address of [Insurer or Risk Retention Group]:
Name of Insured:
Address of Insured:
Certification:
1. [Name of Insurer or Risk Retention Group],
				[the "Insurer" or "Group"], as identified above, hereby certifies that it has
				issued liability insurance covering the following underground storage tank(s):
[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 WAC
				  173-360A-0200, and the name and
				  address of the facility.]
for [insert: "Taking remedial 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
				  "each occurrence" and "annual aggregate" limits of the Insurer's or Group'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" or "Group"] further
				certifies the following with respect to the insurance described in Paragraph 1:
a. Bankruptcy or insolvency of the insured
				does not relieve the ["Insurer" or "Group"] of its obligations under the policy
				to which this certificate applies.
b. The ["Insurer" or "Group"] is liable for
				the payment of amounts within any deductible applicable to the policy to the
				provider of remedial action or a damaged third-party, with a right of
				reimbursement by the insured for any such payment made by the ["Insurer" or
				"Group"]. 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 WAC
				173-360A-1060 through
				173-360A-1065,
				173-360A-1067, and
				173-360A-1070 through
				173-360A-1073.
c. Whenever requested by the Washington State
				Department of Ecology, the ["Insurer" or "Group"] agrees to furnish the
				Department a signed duplicate original of the policy and all
				endorsements.
d. Cancellation or
				any other termination of the insurance by the ["Insurer" or "Group"], 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. 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 10 days
				after a copy of such notice is received by the insured.
[Insert for claims-made policies:
e. The insurance covers claims otherwise
				covered by the policy that are reported to the ["Insurer" or "Group"] within
				six months of the effective date of the 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 WAC
				  173-360A-1083 and that the
				  ["Insurer" or "Group"] 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 or
				  Risk Retention Group]
[Address of Representative]
Certificate Holder:
Business Licensing Service
P.O. Box 9034
Olympia, WA 98507-9034