Form FDACS-13616 "Certificate of General Liability Insurance Pertaining to Pest Control Business License" - Florida

What Is Form FDACS-13616?

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-13616 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-13616 "Certificate of General Liability Insurance Pertaining to Pest Control Business License" - Florida

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Florida Department of Agriculture and Consumer Services
Division of Agricultural Environmental Services
Respond to:
Bureau of Licensing and
Enforcement
CERTIFICATE OF GENERAL LIABILITY INSURANCE
3125 Conner Blvd, Bldg 8,
Tallahassee, FL 32399-1650
PERTAINING TO PEST CONTROL BUSINESS LICENSE
NICOLE "NIKKI" FRIED
Section 482.071(4), F.S. and 5E-14.142, F.A.C.
COMMISSIONER
Telephone: 850-617-7997
Insured:
PRODUCER:
(Pest Control Business)
(Insurance Agent)
____________________________________
_______________________________________
Business Name
Company Name
____________________________________________
_______________________________________________
Physical Address of Business
Street or Mailing Address
____________________________________________
_______________________________________________
City, State, Zip Code
City, State, Zip Code
_______________________________________________
Phone number
_____________________________________________
Insurance Company(ies) Affording Coverage:
Policy Number
_____________________________________________
_______________________________________
Policy Effective Date
Company (Letter A - below)
_____________________________________________
_______________________________________________
Company (Letter B - below)
Policy Expiration Date
A. Chapter 482.071(4), Florida Statutes, states, in part, that each person making application for a pest control business license
or renewal thereof must furnish to the department a certificate of insurance that meets the requirements for minimum financial
responsibility for bodily injury and property damage consisting of:
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
Combined single-limit coverage: $500,000 in the aggregate.
The insured firm’s coverage meets or exceeds the minimum statutory requirements as stated in “A” above:
____________________________________________________
Authorized Insurance Representative Signature
B. Does the insured have insurance for performing wood-destroying organism inspections in the form of errors and omissions
(professional liability) coverage in an amount no less than $500,000 in the aggregate and $250,000 per occurrence?
__________
__________
____________________________________________________
Yes
No
Authorized Insurance Representative Signature
CERTIFICATE HOLDER
Florida Department of Agriculture and Consumer Services
Bureau of Licensing and Enforcement
3125 Conner Blvd, Bldg 8
Tallahassee, FL 32399-1650
(850) 617-7997 FAX: (850) 617-7967
FDACS-13616 Rev. 07/14
Florida Department of Agriculture and Consumer Services
Division of Agricultural Environmental Services
Respond to:
Bureau of Licensing and
Enforcement
CERTIFICATE OF GENERAL LIABILITY INSURANCE
3125 Conner Blvd, Bldg 8,
Tallahassee, FL 32399-1650
PERTAINING TO PEST CONTROL BUSINESS LICENSE
NICOLE "NIKKI" FRIED
Section 482.071(4), F.S. and 5E-14.142, F.A.C.
COMMISSIONER
Telephone: 850-617-7997
Insured:
PRODUCER:
(Pest Control Business)
(Insurance Agent)
____________________________________
_______________________________________
Business Name
Company Name
____________________________________________
_______________________________________________
Physical Address of Business
Street or Mailing Address
____________________________________________
_______________________________________________
City, State, Zip Code
City, State, Zip Code
_______________________________________________
Phone number
_____________________________________________
Insurance Company(ies) Affording Coverage:
Policy Number
_____________________________________________
_______________________________________
Policy Effective Date
Company (Letter A - below)
_____________________________________________
_______________________________________________
Company (Letter B - below)
Policy Expiration Date
A. Chapter 482.071(4), Florida Statutes, states, in part, that each person making application for a pest control business license
or renewal thereof must furnish to the department a certificate of insurance that meets the requirements for minimum financial
responsibility for bodily injury and property damage consisting of:
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
Combined single-limit coverage: $500,000 in the aggregate.
The insured firm’s coverage meets or exceeds the minimum statutory requirements as stated in “A” above:
____________________________________________________
Authorized Insurance Representative Signature
B. Does the insured have insurance for performing wood-destroying organism inspections in the form of errors and omissions
(professional liability) coverage in an amount no less than $500,000 in the aggregate and $250,000 per occurrence?
__________
__________
____________________________________________________
Yes
No
Authorized Insurance Representative Signature
CERTIFICATE HOLDER
Florida Department of Agriculture and Consumer Services
Bureau of Licensing and Enforcement
3125 Conner Blvd, Bldg 8
Tallahassee, FL 32399-1650
(850) 617-7997 FAX: (850) 617-7967
FDACS-13616 Rev. 07/14