WAC 173-360-480
Appendix D -- Certificate of insurance.
CERTIFICATE OF INSURANCE
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 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 173-360-200, 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
"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 shall 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 corrective 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 173-360-413 through 173-360-433.
c. Whenever requested by the director of the Washington
state department of ecology, the ["insurer" or "group"] agrees to
furnish the director 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 173-360-480 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]
[Statutory Authority: Chapter 90.76 RCW. 91-22-020 (Order
91-26), § 173-360-480, filed 10/29/91, effective 11/29/91;
90-24-017, § 173-360-480, filed 11/28/90, effective 12/29/90.]
NOTES:
Reviser's note: The brackets and enclosed material in the text of the above section occurred in the copy filed by the agency.