Form DP-44A "Proof of Financial Responsibility Certificate Using Insurance" - Arkansas

What Is Form DP-44A?

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

Form Details:

  • Released on July 1, 2010;
  • The latest edition provided by the Arkansas Agriculture Department;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a printable version of Form DP-44A by clicking the link below or browse more documents and templates provided by the Arkansas Agriculture Department.

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Download Form DP-44A "Proof of Financial Responsibility Certificate Using Insurance" - Arkansas

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Form DP-44A (Rev. 07-10)
ARKANSAS STATE PLANT BOARD – PESTICIDE DIVISION
PROOF OF FINANCIAL RESPONSIBILITY CERTIFICATE USING INSURANCE
This is to certify that an insurance policy, which is in accordance with the insurance laws of the State of Arkansas, has been
issued to:
Name
Address
________________________________________
_______________________________________________
________
City
State
Zip
_________________________________________
________________________
____________
Insurance Company Name___________________________________________________________________________
Policy
Effective Date
Expiration Date
/Form Number__________________________
________________
______________
This policy includes pesticide application coverage.
NAIC#
______________________________________
LIMITS OF LIABILITY (Applicable to pesticide coverage)
Pesticide Application Coverage $
Deductible
____________________________________
__________________________
Does this policy cover the applications of 2,4-D containing compound? Yes
No
List any pesticides not covered by this policy:
__________________________________________________
________________________________________________________________________________________________________________________________
Application Equipment Covered:
“N” or other
Type (Ground/Aircraft)
Model
Identification Number
_______________________________
______________________________
__________________________
_______________________________
______________________________
__________________________
_______________________________
______________________________
__________________________
_______________________________
______________________________
__________________________
_______________________________
______________________________
__________________________
_______________________________
______________________________
__________________________
(List additional equipment on separate sheet and attach)
List approved pilots
____________________________________________________________________________________
By signature below the named Commercial Applicator attests that the policy identified meets the liability requirements as
.
specified by ACA 20-20-209 (d) and the regulations promulgated pursuant thereto
Commercial Applicator Signature__________________________________________
Date_________________
**Original Signature is Required, Photocopies cannot be Accepted.
**Return this form to the Arkansas State Plant Board, P.O. Box 1069, Little Rock, AR 72203
Form DP-44A (Rev. 07-10)
ARKANSAS STATE PLANT BOARD – PESTICIDE DIVISION
PROOF OF FINANCIAL RESPONSIBILITY CERTIFICATE USING INSURANCE
This is to certify that an insurance policy, which is in accordance with the insurance laws of the State of Arkansas, has been
issued to:
Name
Address
________________________________________
_______________________________________________
________
City
State
Zip
_________________________________________
________________________
____________
Insurance Company Name___________________________________________________________________________
Policy
Effective Date
Expiration Date
/Form Number__________________________
________________
______________
This policy includes pesticide application coverage.
NAIC#
______________________________________
LIMITS OF LIABILITY (Applicable to pesticide coverage)
Pesticide Application Coverage $
Deductible
____________________________________
__________________________
Does this policy cover the applications of 2,4-D containing compound? Yes
No
List any pesticides not covered by this policy:
__________________________________________________
________________________________________________________________________________________________________________________________
Application Equipment Covered:
“N” or other
Type (Ground/Aircraft)
Model
Identification Number
_______________________________
______________________________
__________________________
_______________________________
______________________________
__________________________
_______________________________
______________________________
__________________________
_______________________________
______________________________
__________________________
_______________________________
______________________________
__________________________
_______________________________
______________________________
__________________________
(List additional equipment on separate sheet and attach)
List approved pilots
____________________________________________________________________________________
By signature below the named Commercial Applicator attests that the policy identified meets the liability requirements as
.
specified by ACA 20-20-209 (d) and the regulations promulgated pursuant thereto
Commercial Applicator Signature__________________________________________
Date_________________
**Original Signature is Required, Photocopies cannot be Accepted.
**Return this form to the Arkansas State Plant Board, P.O. Box 1069, Little Rock, AR 72203