Form FDACS-13654 "Certificate of Insurance" - Florida

What Is Form FDACS-13654?

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

Form Details:

  • Released on July 1, 2014;
  • The latest edition provided by the Florida Department of Agriculture and Consumer Services;
  • 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 FDACS-13654 by clicking the link below or browse more documents and templates provided by the Florida Department of Agriculture and Consumer Services.

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Download Form FDACS-13654 "Certificate of Insurance" - Florida

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Florida Department of Agriculture and Consumer Services
Division of Agricultural Environmental Services
Respond to:
CERTIFICATE OF INSURANCE
Bureau of Licensing and
Enforcement
3125 Conner Blvd, Bldg 8,
Rule 5E-14.117, F.A.C.
Tallahassee, FL 32399-1650
NICOLE "NIKKI" FRIED
Telephone: (850) 617-7997; Fax (850) 617-7967
COMMISSIONER
Please check the type of business your insurance is applicable to:
Commercial Landscape Maintenance
Commercial Wildlife Management
PRODUCER:
Insured:
(Insurance Agent)
Company Name
Company Name
Company Business Location Address
Company Business Location Address
City, State, Zip Code
City, State, Zip Code
______________________________________________
Insured Company Affording Coverage:
Individual’s Name (for Landscape and Wildlife applicants)
Company Name
Policy Number
Policy effective date
Policy expiration date
Section(s) 482.071(4), 482.156(2)(a), and 482.157(2)(c), Florida Statutes, states, in part, “Each person making
application for certification under this section must furnish proof of having a certificate of insurance, as required by
Section 482.071(4), Florida Statutes”, which states that the employer or individual meets the requirements for minimum
financial responsibility for bodily injury and property damage consisting of:
(A)
Bodily injury: $250,000 each person and $500,000 each occurrence; and
Property damage: $250,000 each occurrence and $500,000 in the aggregate; or
(B)
Combined single-limit coverage: $500,000 in the aggregate.
The insured’s coverage meets or exceeds the minimum statutory requirement as stated above:
Authorized Insurance Representative
CERTIFICATE HOLDER
Florida Department of Agriculture and Consumer Services
Bureau of Licensing and Enforcement
3125 Conner Blvd, Bldg 8,
Tallahassee, Florida 32399-1650
FDACS-13654 Rev. 07/14
Florida Department of Agriculture and Consumer Services
Division of Agricultural Environmental Services
Respond to:
CERTIFICATE OF INSURANCE
Bureau of Licensing and
Enforcement
3125 Conner Blvd, Bldg 8,
Rule 5E-14.117, F.A.C.
Tallahassee, FL 32399-1650
NICOLE "NIKKI" FRIED
Telephone: (850) 617-7997; Fax (850) 617-7967
COMMISSIONER
Please check the type of business your insurance is applicable to:
Commercial Landscape Maintenance
Commercial Wildlife Management
PRODUCER:
Insured:
(Insurance Agent)
Company Name
Company Name
Company Business Location Address
Company Business Location Address
City, State, Zip Code
City, State, Zip Code
______________________________________________
Insured Company Affording Coverage:
Individual’s Name (for Landscape and Wildlife applicants)
Company Name
Policy Number
Policy effective date
Policy expiration date
Section(s) 482.071(4), 482.156(2)(a), and 482.157(2)(c), Florida Statutes, states, in part, “Each person making
application for certification under this section must furnish proof of having a certificate of insurance, as required by
Section 482.071(4), Florida Statutes”, which states that the employer or individual meets the requirements for minimum
financial responsibility for bodily injury and property damage consisting of:
(A)
Bodily injury: $250,000 each person and $500,000 each occurrence; and
Property damage: $250,000 each occurrence and $500,000 in the aggregate; or
(B)
Combined single-limit coverage: $500,000 in the aggregate.
The insured’s coverage meets or exceeds the minimum statutory requirement as stated above:
Authorized Insurance Representative
CERTIFICATE HOLDER
Florida Department of Agriculture and Consumer Services
Bureau of Licensing and Enforcement
3125 Conner Blvd, Bldg 8,
Tallahassee, Florida 32399-1650
FDACS-13654 Rev. 07/14