Form FDACS-03588 "Lp Gas Insurance Affidavit" - Florida

Form FDACS-03588 is a Florida Department of Agriculture and Consumer Services form also known as the "Lp Gas Insurance Affidavit". The latest edition of the form was released in August 1, 2018 and is available for digital filing.

Download an up-to-date fillable Form FDACS-03588 in PDF-format down below or look it up on the Florida Department of Agriculture and Consumer Services Forms website.

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Download Form FDACS-03588 "Lp Gas Insurance Affidavit" - Florida

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Florida Department of Agriculture and Consumer Services
Division of Consumer Services
LP GAS INSURANCE AFFIDAVIT
ADAM H. PUTNAM
Section 527.04, Florida Statutes
COMMISSIONER
In order to hold a valid LP license in this state, Chapter 527, Florida Statutes, requires each licensee to have and maintain a primary policy
of insurance coverage in the amount of $300,000 (Category 3 - Cylinder Exchange Operator) or $1,000,000 (Category 1 - Dealer, Category
2- Dispenser, Category 5 - Installer, or Category 6 - Miscellaneous). This policy must include bodily injury liability and property damage
insurance covering the products and operations of the business. Insurance company forms are acceptable; however, this form may be
used to provide documentation of insurance. THIS FORM MUST BE NOTARIZED in accordance with Section 92.50, Florida Statutes.
Questions should be directed to the Bureau of Compliance at (850) 921-1600.
(PLEASE PRINT OR TYPE - MUST BE COMPLETED BY LP GAS LICENSE HOLDER/APPLICANT)
,
,
I,
Category Type_________
NAME OF APPLICANT/COMPANY OFFICIAL
TITLE OR OFFICE HELD
DO CERTIFY THAT
LP GAS LICENSEE NAME (AS IT APPEARS ON THE LP GAS LICENSE)
who holds Florida LP Gas License Number (if issued)
, has a primary policy of bodily injury liability and
property damage liability insurance covering the products and operations of such business as required by Section 527.04, Florida Statutes.
Said policy is issued by an insurer authorized to do business in Florida and is for an amount not less than
$300,000 or
$1,000,000, as required by law.
Name of insured as it appears on the policy
Specific address of insured’s location covered by the policy
Insurance Company
Name of insurance agent or insurance agency
Address of insurance agent or insurance agency
Telephone Number
_______________________________________
Policy Number
Effective Dates (Include beginning & ending date)
A separate affidavit must be submitted covering each individual licensed location where the insured conducts LP gas operations in the state
of Florida. FAILURE TO MAINTAIN CURRENT INSURANCE SHALL RESULT IN LICENSE CANCELLATION.
I understand as a condition of holding a liquefied petroleum gas license, a valid primary policy in an amount of not less than
$300,000 or
$1,000,000 must remain in full force and effect during the period of the policy and at all times that
the licensee is conducting LP gas activities.
SWORN TO AND SUBSCRIBED BEFORE ME
THIS
DAY OF
20
SIGNATURE OF LICENSE APPLICANT/COMPANY OFFICIAL
NOTARY PUBLIC
DATE
FDACS-03588 08/18
Florida Department of Agriculture and Consumer Services
Division of Consumer Services
LP GAS INSURANCE AFFIDAVIT
ADAM H. PUTNAM
Section 527.04, Florida Statutes
COMMISSIONER
In order to hold a valid LP license in this state, Chapter 527, Florida Statutes, requires each licensee to have and maintain a primary policy
of insurance coverage in the amount of $300,000 (Category 3 - Cylinder Exchange Operator) or $1,000,000 (Category 1 - Dealer, Category
2- Dispenser, Category 5 - Installer, or Category 6 - Miscellaneous). This policy must include bodily injury liability and property damage
insurance covering the products and operations of the business. Insurance company forms are acceptable; however, this form may be
used to provide documentation of insurance. THIS FORM MUST BE NOTARIZED in accordance with Section 92.50, Florida Statutes.
Questions should be directed to the Bureau of Compliance at (850) 921-1600.
(PLEASE PRINT OR TYPE - MUST BE COMPLETED BY LP GAS LICENSE HOLDER/APPLICANT)
,
,
I,
Category Type_________
NAME OF APPLICANT/COMPANY OFFICIAL
TITLE OR OFFICE HELD
DO CERTIFY THAT
LP GAS LICENSEE NAME (AS IT APPEARS ON THE LP GAS LICENSE)
who holds Florida LP Gas License Number (if issued)
, has a primary policy of bodily injury liability and
property damage liability insurance covering the products and operations of such business as required by Section 527.04, Florida Statutes.
Said policy is issued by an insurer authorized to do business in Florida and is for an amount not less than
$300,000 or
$1,000,000, as required by law.
Name of insured as it appears on the policy
Specific address of insured’s location covered by the policy
Insurance Company
Name of insurance agent or insurance agency
Address of insurance agent or insurance agency
Telephone Number
_______________________________________
Policy Number
Effective Dates (Include beginning & ending date)
A separate affidavit must be submitted covering each individual licensed location where the insured conducts LP gas operations in the state
of Florida. FAILURE TO MAINTAIN CURRENT INSURANCE SHALL RESULT IN LICENSE CANCELLATION.
I understand as a condition of holding a liquefied petroleum gas license, a valid primary policy in an amount of not less than
$300,000 or
$1,000,000 must remain in full force and effect during the period of the policy and at all times that
the licensee is conducting LP gas activities.
SWORN TO AND SUBSCRIBED BEFORE ME
THIS
DAY OF
20
SIGNATURE OF LICENSE APPLICANT/COMPANY OFFICIAL
NOTARY PUBLIC
DATE
FDACS-03588 08/18
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