Form DPR-PML-052 "Certificate of Insurance" - California

What Is Form DPR-PML-052?

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

Form Details:

  • Released on August 1, 2011;
  • The latest edition provided by the California Department of Pesticide Regulation;
  • 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 fillable version of Form DPR-PML-052 by clicking the link below or browse more documents and templates provided by the California Department of Pesticide Regulation.

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Download Form DPR-PML-052 "Certificate of Insurance" - California

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STATE OF CALIFORNIA
PEST MANAGEMENT AND LICENSING BRANCH
DEPARTMENT OF PESTICIDE REGULATION
1001 I STREET
CERTIFICATE OF INSURANCE
SACRAMENTO, CA 95814-2828
P.O. BOX 4015
DPR-PML-052 (REV. 08/11)
SACRAMENTO, CA 95812-4015
(916) 445-4038
FAX (916) 445-4033
Web site: http://www.cdpr.ca.gov
This is to certify to the Director of the Department of Pesticide Regulation, whose address is 1001 I Street, Sacramento, California
95814-2828 that
(name of business), an applicant for a
pest control business license, is at this date insured with
(Insurance Company) for the Limits of Coverage stated below.
Coverage Descriptive Schedule
Expiration
Limit of Liability
Policy
Limit of Liability
Limit of Liability
Insurance Coverage
Number(s)
Date(s)
Per Person
Per Occurrence
Annual Aggregate
1. Bodily injury including Chemical
Liability
$
$
$
2. Property Damage including
Chemical Liability
$
$
$
3. Combined Single Limit for Bodily
Injury and Property Damage
including Chemical Liability
$
$
$
List of Covered Aircraft (Attach additional sheet if necessary)
Aircraft "N" Number
Aircraft Usages (Chemical Use/Nonchemical Use)
Remarks
1) N
2) N
3) N
Insured Information
PEST CONTROL BUSINESS LICENSE NUMBER
INSURED BUSINESS NAME
(Optional)
STATE
BUSINESS LOCATION ADDRESS
CITY
ZIP CODE
Insurance Company and Insurance Agent/Broker Information
PHONE NUMBER
FAX NUMBER
EMAIL ADDRESS
1. INSURANCE COMPANY NAME
(Optional)
(Optional)
(Optional)
MAILING ADDRESS
STATE
ZIP CODE
CITY
CONTACT PERSON NAME
(Optional)
FAX NUMBER
EMAIL ADDRESS
PHONE NUMBER
(Optional)
2. INSURANCE AGENT/BROKER NAME
(Optional)
(Optional)
(Optional)
MAILING ADDRESS
CITY
STATE
ZIP CODE
(Optional)
(Optional)
(Optional)
(Optional)
CONTACT PERSON NAME
(Optional)
The undersigned hereby certifies that liability insurance issued to the aforementioned insured, fulfills the requirements stated
above and the requirements pursuant to Section 6524, of Title 3, of the California Code of Regulations.
The issuing company agrees that in the event of non-renewal or material change, including cancellation or reduction of coverage
of the policy(ies), the issuing company will endeavor to give the party to whom the Certification is issued 30 days advance notice
of such non-renewal or change, but the issuing company shall not be liable in any way for failure to give such notice.
DATE
INSURANCE REPRESENTATIVE SIGNATURE
STATE OF CALIFORNIA
PEST MANAGEMENT AND LICENSING BRANCH
DEPARTMENT OF PESTICIDE REGULATION
1001 I STREET
CERTIFICATE OF INSURANCE
SACRAMENTO, CA 95814-2828
P.O. BOX 4015
DPR-PML-052 (REV. 08/11)
SACRAMENTO, CA 95812-4015
(916) 445-4038
FAX (916) 445-4033
Web site: http://www.cdpr.ca.gov
This is to certify to the Director of the Department of Pesticide Regulation, whose address is 1001 I Street, Sacramento, California
95814-2828 that
(name of business), an applicant for a
pest control business license, is at this date insured with
(Insurance Company) for the Limits of Coverage stated below.
Coverage Descriptive Schedule
Expiration
Limit of Liability
Policy
Limit of Liability
Limit of Liability
Insurance Coverage
Number(s)
Date(s)
Per Person
Per Occurrence
Annual Aggregate
1. Bodily injury including Chemical
Liability
$
$
$
2. Property Damage including
Chemical Liability
$
$
$
3. Combined Single Limit for Bodily
Injury and Property Damage
including Chemical Liability
$
$
$
List of Covered Aircraft (Attach additional sheet if necessary)
Aircraft "N" Number
Aircraft Usages (Chemical Use/Nonchemical Use)
Remarks
1) N
2) N
3) N
Insured Information
PEST CONTROL BUSINESS LICENSE NUMBER
INSURED BUSINESS NAME
(Optional)
STATE
BUSINESS LOCATION ADDRESS
CITY
ZIP CODE
Insurance Company and Insurance Agent/Broker Information
PHONE NUMBER
FAX NUMBER
EMAIL ADDRESS
1. INSURANCE COMPANY NAME
(Optional)
(Optional)
(Optional)
MAILING ADDRESS
STATE
ZIP CODE
CITY
CONTACT PERSON NAME
(Optional)
FAX NUMBER
EMAIL ADDRESS
PHONE NUMBER
(Optional)
2. INSURANCE AGENT/BROKER NAME
(Optional)
(Optional)
(Optional)
MAILING ADDRESS
CITY
STATE
ZIP CODE
(Optional)
(Optional)
(Optional)
(Optional)
CONTACT PERSON NAME
(Optional)
The undersigned hereby certifies that liability insurance issued to the aforementioned insured, fulfills the requirements stated
above and the requirements pursuant to Section 6524, of Title 3, of the California Code of Regulations.
The issuing company agrees that in the event of non-renewal or material change, including cancellation or reduction of coverage
of the policy(ies), the issuing company will endeavor to give the party to whom the Certification is issued 30 days advance notice
of such non-renewal or change, but the issuing company shall not be liable in any way for failure to give such notice.
DATE
INSURANCE REPRESENTATIVE SIGNATURE