"Georgia Structural Pest Control Act Insurance Certification Form" - Georgia (United States)

Georgia Structural Pest Control Act Insurance Certification Form is a legal document that was released by the Georgia Department of Agriculture - a government authority operating within Georgia (United States).

Form Details:

  • Released on May 1, 2017;
  • The latest edition currently provided by the Georgia Department of Agriculture;
  • Ready to use and print;
  • Easy to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a printable version of the form by clicking the link below or browse more documents and templates provided by the Georgia Department of Agriculture.

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Structural Pest Section
19 Martin Luther King, Jr. Dr.
Atlanta, Georgia 30334-4201
Phone: (404) 656-3641
insurance@agr.georgia.gov
Guidance for completing the Georgia Structural Pest Control Insurance Form
This guidance is for structural pest control companies. This form and required attachment(s) must be submitted to
the Structural Pest Control Section of the Georgia Department of Agriculture. The requirement to maintain the
insurance policy and submit verification is specified in the Georgia Structural Pest Control Act.
What is required on the form?
The following information is required on the form:
Pest Control Company name
License number
o
Address
o
City, State & Zip
o
Indicate licensed category(ies): Fumigation, Household Pest Control or Wood Destroying Organism
o
Insurance company name
Policy Number
o
Effective date
o
Expiration date
o
Printed Name and Signature of DCO or authorized agent of the pest control company
What should be attached to the form?
Certificate of Liability Insurance form. This certificate is often referred to as the “ACORD 25”
Endorsements: The following endorsements must be identified on the certificate or attached separately:
Pollution liability coverage’s
o
Errors and Omissions if operating in Wood Destroying Organisms category
o
Cancellation provision notification to the Department
o
When is the form required to be submitted to the Department?
Each time the policy is renewed (typically on an annual basis)
A new policy is issued
New application for company license
5-2017
Structural Pest Section
19 Martin Luther King, Jr. Dr.
Atlanta, Georgia 30334-4201
Phone: (404) 656-3641
insurance@agr.georgia.gov
Guidance for completing the Georgia Structural Pest Control Insurance Form
This guidance is for structural pest control companies. This form and required attachment(s) must be submitted to
the Structural Pest Control Section of the Georgia Department of Agriculture. The requirement to maintain the
insurance policy and submit verification is specified in the Georgia Structural Pest Control Act.
What is required on the form?
The following information is required on the form:
Pest Control Company name
License number
o
Address
o
City, State & Zip
o
Indicate licensed category(ies): Fumigation, Household Pest Control or Wood Destroying Organism
o
Insurance company name
Policy Number
o
Effective date
o
Expiration date
o
Printed Name and Signature of DCO or authorized agent of the pest control company
What should be attached to the form?
Certificate of Liability Insurance form. This certificate is often referred to as the “ACORD 25”
Endorsements: The following endorsements must be identified on the certificate or attached separately:
Pollution liability coverage’s
o
Errors and Omissions if operating in Wood Destroying Organisms category
o
Cancellation provision notification to the Department
o
When is the form required to be submitted to the Department?
Each time the policy is renewed (typically on an annual basis)
A new policy is issued
New application for company license
5-2017
GEORGIA STRUCTURAL PEST CONTROL ACT INSURANCE CERTIFICATION FORM
Insured________________________________________________________ License No._________________
Addresss__________________________________________________________________________________
City______________________________________State__________________Zip Code___________________
Insurance Company__________________________________________________________________________
Policy No.____________________ Effective Date _________________Expiration Date __________________
Licensed Categories: _____ Fumigation _____ Household Pest Control _____ Wood-destroying Organism
MINIMUM LIMITS REQUIRED
MINIMUM LIMITS REQUIRED
FOR WOOD-DESTROYING ORGANISM LICENSE
FOR PEST CONTROL AND/OR FUMIGATION LICENSE
Bodily Injury: Any One Occurrence . . . .
$50,000
Bodily Injury: Any One Occurrence . .
.
$100,000
Property Damage: Any One Occurrence .
. $100,000
Property Damage: Any One Occurrence .
. $50,000
Minimum Annual Aggregate . . . .
. . $200,000
Minimum Annual Aggregate . . . .
. . $500,000
INSURANCE REQUIREMENTS
Insurance coverage is required by the Georgia Structural Pest Control Act. The company must keep coverage active and
meet the minimum requirements as specified in O.C.G.A. 43-45-9 and on this form.
Liability for bodily injury and property damage claims: Coverage as specified by category on this form.
Pollution Liability: Coverage for claims caused by sudden and accidental discharge or release of pollutants.
Errors and Omissions: Licensees for the control of wood-destroying organisms shall have coverage for claims arising
from the licensee’s treatment or services for control of wood-destroying organisms including errors and omission coverage
on an occurrence basis.
Cancellation: Policy must contain a cancellation provision whereby notification of cancellation is made by the insurer to
and received by the Georgia Department of Agriculture no less than 30 days prior to the cancellation.
Certificate of Liability Insurance form and endorsements: This certificate must be executed by an authorized
representative of the insurance producer. The certificate and endorsements must be included with this form.
This form and attachments shall serve as verification of the company holding all of the insurance coverage requirements. By signing below, the authorized
representative certifies that the licensee maintains the required insurance coverage at this time and throughout the license period and in the minimum
amounts specified in O.C.G.A. 43-45-9 and on this form. Failure to maintain minimum required coverage will result in automatic license suspension. If
license is not reinstated within three months, it shall be revoked by operation of law without a hearing.
Signature of Designated Certified Operator Print
Name/Signature_______________________________________/__________________________________________
5-2017
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