DEP Form 62-730.900(4)(O) "Certificate of Valid Claim Example" - Florida

What Is DEP Form 62-730.900(4)(O)?

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

Form Details:

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Download a fillable version of DEP Form 62-730.900(4)(O) by clicking the link below or browse more documents and templates provided by the Florida Department of Environmental Protection.

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Download DEP Form 62-730.900(4)(O) "Certificate of Valid Claim Example" - Florida

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Reference:
Facility name:
FDEP I.D. Number:
Bank Name:
Letter of Credit Number:
Certificate of Valid Claim
The undersigned, as parties
(hereinafter
[Owner or Operator]
the “Principal”) and
[Name of Third Party Claimant(s)]
(hereinafter the “Claimant(s)”),
,
[Address of Third Party Claimant(s)]
hereby certify that the claim of bodily injury and/or property damage caused by a
[insert “sudden” or “nonsudden”]
accidental occurrence arising from the operations of the Principal’s hazardous waste treatment, storage or
disposal facility should be paid in the amount of $
. We hereby certify that the claim
does not apply to any of the following:
(a)
Bodily injury or property damage for which the Principal is obligated to pay damages by reason of the
assumption of liability in a contract or agreement. This exclusion does not apply to liability for damages that
the Principal would be obligated to pay in the absence of the contract or agreement.
(b)
Any obligation of the Principal under a workers’ compensation, disability benefits or unemployment
compensation law or any similar law.
(c)
Bodily injury to:
(1) An employee of the Principal arising from, and in the course of, employment by the Principal; or
(2) The spouse, child, parent, brother or sister of that employee as a consequence of, or arising from, and in
the course of employment by the Principal.
This exclusion applies:
(A) Whether the Principal may be liable as an employer or in any other capacity; and
(B) To any obligation to share damages with or repay another person who must pay damages because of
the injury to persons identified in paragraphs (1) and (2).
(d)
Bodily injury or property damage arising out of the ownership, maintenance, use or entrustment to others of
any aircraft, motor vehicle or watercraft.
(e)
Property damage to:
(1) Any property owned, rented or occupied by the Principal;
(2) Premises that are sold, given away or abandoned by if the property damage arises out of any part of
those premises;
(3) Property loaned to the Principal;
(4) Personal property in the care, custody or control of the Principal;
(5) That particular part of real property on which or any contractors or subcontractors working directly or
indirectly on behalf of the Principal are performing operations, if the property damage arises out of these
operations.
For the Claimant(s)
For the Principal
[Signature by Authorized Representative of Claimant(s)]
[Signature by Authorized Representative of Principal]
[Name and Title of Claimant(s)’s Authorized Representative]
[Name and Title of Principal’s Authorized Representative]
[Claimant(s)’s Phone and/or E-mail Address]
[Principal’s Phone and/or E-mail Address]
Date signed
Date signed]
This is an example of a Certificate of Valid Claim as specified in DEP Form 62-730.900(4)(o)
This is an example of a Certificate of Valid Claim as specified in DEP Form 62-730.900(4)(o)
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Reference:
Facility name:
FDEP I.D. Number:
Bank Name:
Letter of Credit Number:
Certificate of Valid Claim
The undersigned, as parties
(hereinafter
[Owner or Operator]
the “Principal”) and
[Name of Third Party Claimant(s)]
(hereinafter the “Claimant(s)”),
,
[Address of Third Party Claimant(s)]
hereby certify that the claim of bodily injury and/or property damage caused by a
[insert “sudden” or “nonsudden”]
accidental occurrence arising from the operations of the Principal’s hazardous waste treatment, storage or
disposal facility should be paid in the amount of $
. We hereby certify that the claim
does not apply to any of the following:
(a)
Bodily injury or property damage for which the Principal is obligated to pay damages by reason of the
assumption of liability in a contract or agreement. This exclusion does not apply to liability for damages that
the Principal would be obligated to pay in the absence of the contract or agreement.
(b)
Any obligation of the Principal under a workers’ compensation, disability benefits or unemployment
compensation law or any similar law.
(c)
Bodily injury to:
(1) An employee of the Principal arising from, and in the course of, employment by the Principal; or
(2) The spouse, child, parent, brother or sister of that employee as a consequence of, or arising from, and in
the course of employment by the Principal.
This exclusion applies:
(A) Whether the Principal may be liable as an employer or in any other capacity; and
(B) To any obligation to share damages with or repay another person who must pay damages because of
the injury to persons identified in paragraphs (1) and (2).
(d)
Bodily injury or property damage arising out of the ownership, maintenance, use or entrustment to others of
any aircraft, motor vehicle or watercraft.
(e)
Property damage to:
(1) Any property owned, rented or occupied by the Principal;
(2) Premises that are sold, given away or abandoned by if the property damage arises out of any part of
those premises;
(3) Property loaned to the Principal;
(4) Personal property in the care, custody or control of the Principal;
(5) That particular part of real property on which or any contractors or subcontractors working directly or
indirectly on behalf of the Principal are performing operations, if the property damage arises out of these
operations.
For the Claimant(s)
For the Principal
[Signature by Authorized Representative of Claimant(s)]
[Signature by Authorized Representative of Principal]
[Name and Title of Claimant(s)’s Authorized Representative]
[Name and Title of Principal’s Authorized Representative]
[Claimant(s)’s Phone and/or E-mail Address]
[Principal’s Phone and/or E-mail Address]
Date signed
Date signed]
This is an example of a Certificate of Valid Claim as specified in DEP Form 62-730.900(4)(o)
This is an example of a Certificate of Valid Claim as specified in DEP Form 62-730.900(4)(o)