DEP Form 62-761.900(3) "Storage Tank Certificate of Insurance" - Florida

What Is DEP Form 62-761.900(3)?

This is a legal form that was released by the Florida Department of Environmental Protection - a government authority operating within Florida. As of today, no separate filing guidelines for the form are provided by the issuing department.

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Download a fillable version of DEP Form 62-761.900(3) by clicking the link below or browse more documents and templates provided by the Florida Department of Environmental Protection.

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Download DEP Form 62-761.900(3) "Storage Tank Certificate of Insurance" - Florida

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Financial instruments kept off-site shall be made
DEP Form 62-761.900(3)
available for inspection upon five business days notice
Form Title: Financial Mechanisms for Storage Tanks
Part D: ST Certificate of Insurance
Form Effective Date January 2017
Guidance:
http://www.dep.state.fl.us/waste/categories/tanksfr/default.htm
Incorporated in Rules 62-761.420 and 62-762.421, F.A.C.
STATE OF FLORIDA
STORAGE TANK CERTIFICATE OF INSURANCE
Reference: 40 CFR 280.97(b)(2)
Insurer or Risk Retention Group:
FL insurance companies
, (herein referred to as “Insurer”),
[Name of Insurer or Risk Retention Group]
[Business address of Insurer or Risk Retention Group]
“Insurer” is a(n)
.
[Enter "insurer" or "risk retention group"]
Insured:
Sunbiz
[Name of owner or operator]
[Business address of owner or operator]
Policy Number:
Endorsement Number:
[If applicable]
Period of Coverage:
Policy Effective Date:
[Current policy period]
Covered Locations:
[List for each facility covered: the FDEP identification number and the name and site address of the facility where tanks assured by this instrument are
located and the number of tanks at that
site.
If separate mechanisms or combinations of mechanisms are being used to assure any of the tanks at this
facility, list each tank assured by this instrument by the tank identification number provided in the notification submitted pursuant to Rules 62-761.400
and 62-762.401, F.A.C. If coverage is different for different tanks or locations, indicate the type of coverage applicable to each tank or location. Indicate
“See attachment” if required.]
FDEP FacID
Facility Name and Site Address
Number of Tanks or Tank I.D. Nos.
Certification:
1. “Insurer” hereby certifies that it has issued to the Insured the liability insurance identified above to provide financial
assurance for
caused by
[Insert "corrective action" and/or "compensating third parties for bodily injury and property damage"]
in accordance with and subject to the limits
[Insert "sudden accidental releases" or "nonsudden accidental releases" or “accidental releases”]
of liability, exclusions, conditions, and other terms of the policy arising from operating the facilities/tanks identified above.
The Insurer further warrants that such policy conforms in all respects with the requirements of 40 CFR 280.97(b), as
adopted by reference in Rule(s) 62-761.420 and/or 62-762.421, Florida Administrative Code (F.A.C.) for the above
specified financial assurance. It is agreed that any provision of the policy inconsistent with such regulations is hereby
amended to eliminate such inconsistency.
Part D page 1 of 2
DEP Form 62-761.900(3)
Entire form page 10 of 42
CLEAR
PRINT
SAVE
Financial instruments kept off-site shall be made
DEP Form 62-761.900(3)
available for inspection upon five business days notice
Form Title: Financial Mechanisms for Storage Tanks
Part D: ST Certificate of Insurance
Form Effective Date January 2017
Guidance:
http://www.dep.state.fl.us/waste/categories/tanksfr/default.htm
Incorporated in Rules 62-761.420 and 62-762.421, F.A.C.
STATE OF FLORIDA
STORAGE TANK CERTIFICATE OF INSURANCE
Reference: 40 CFR 280.97(b)(2)
Insurer or Risk Retention Group:
FL insurance companies
, (herein referred to as “Insurer”),
[Name of Insurer or Risk Retention Group]
[Business address of Insurer or Risk Retention Group]
“Insurer” is a(n)
.
[Enter "insurer" or "risk retention group"]
Insured:
Sunbiz
[Name of owner or operator]
[Business address of owner or operator]
Policy Number:
Endorsement Number:
[If applicable]
Period of Coverage:
Policy Effective Date:
[Current policy period]
Covered Locations:
[List for each facility covered: the FDEP identification number and the name and site address of the facility where tanks assured by this instrument are
located and the number of tanks at that
site.
If separate mechanisms or combinations of mechanisms are being used to assure any of the tanks at this
facility, list each tank assured by this instrument by the tank identification number provided in the notification submitted pursuant to Rules 62-761.400
and 62-762.401, F.A.C. If coverage is different for different tanks or locations, indicate the type of coverage applicable to each tank or location. Indicate
“See attachment” if required.]
FDEP FacID
Facility Name and Site Address
Number of Tanks or Tank I.D. Nos.
Certification:
1. “Insurer” hereby certifies that it has issued to the Insured the liability insurance identified above to provide financial
assurance for
caused by
[Insert "corrective action" and/or "compensating third parties for bodily injury and property damage"]
in accordance with and subject to the limits
[Insert "sudden accidental releases" or "nonsudden accidental releases" or “accidental releases”]
of liability, exclusions, conditions, and other terms of the policy arising from operating the facilities/tanks identified above.
The Insurer further warrants that such policy conforms in all respects with the requirements of 40 CFR 280.97(b), as
adopted by reference in Rule(s) 62-761.420 and/or 62-762.421, Florida Administrative Code (F.A.C.) for the above
specified financial assurance. It is agreed that any provision of the policy inconsistent with such regulations is hereby
amended to eliminate such inconsistency.
Part D page 1 of 2
DEP Form 62-761.900(3)
Entire form page 10 of 42
The limits of liability are:
Each Occurrence: $
Annual Aggregate: $
[If the amount of coverage is different for different types of coverage or for different storage tanks or locations, indicate on the facility list above or by
separate attachment the amount of coverage for each type of coverage and/or for each storage tank or location.]
exclusive of legal defense costs, which are subject to a separate limit under the policy.
2. “Insurer” further certifies the following with respect to this policy:
a. Bankruptcy or insolvency of the insured shall not relieve “Insurer” of its obligations under the policy to which this
certificate applies.
b. “Insurer” 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 “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
40 CFR 280.95 - 280.102 and 280.104 - 280.107.
c. Whenever requested by the Florida Department of Environmental Protection (FDEP) Secretary or the Secretary's
designee ("designee"), “Insurer” agrees to furnish, to the FDEP Secretary or designee, a signed duplicate original
of the policy and all endorsements.
d. Cancellation or any other termination of the insurance by “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. 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 10 days after a copy of such written notice is received by the insured.
Check this box if the following paragraph, for claims-made policies, applies
.
e. The insurance covers claims otherwise covered by the policy that are reported to “Insurer” within six months of
the effective date of cancellation or non-renewal 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.
The person whose signature appears below hereby certifies that the wording of this instrument is identical to the wording
as adopted and incorporated by reference in subsection(s) 62-761.420(4) and/or 62-762.421(4), F.A.C., and that “Insurer” is
.
[Insert "licensed to transact the business of insurance” or “eligible to provide insurance as an excess or surplus lines insurer in Florida"]
Embossed seal of “Insurer” must be included.
[Signature of Authorized Representative of Insurer]
[Name and Title]
[Address]
[Telephone Number]
[Email Address]
[Signature of Witness or Notary]
[Date of Witness or Notary]
[Printed Name of Witness or include Notary Seal]
Part D page 2 of 2
DEP Form 62-761.900(3)
Entire form page 11 of 42
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