DEP Form 62-730.900(4)(K) "Hazardous Waste Facility Certificate of Liability Insurance (Primary Policy)" - Florida

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

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:

  • Released on January 5, 1995;
  • The latest edition provided by the Florida Department of Environmental Protection;
  • 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 DEP Form 62-730.900(4)(K) 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)(K) "Hazardous Waste Facility Certificate of Liability Insurance (Primary Policy)" - Florida

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DEP Form # 62-730.900(4)(k)
Form Title HW Certificate of Liability Insurance
Effective Date January 5, 1995
DEP Application No.
STATE OF FLORIDA
HAZARDOUS WASTE FACILITY CERTIFICATE OF LIABILITY INSURANCE
(Primary Policy)
1.
,(the "Insurer"),
Name of Insurer
of
Address of Insurer
hereby certifies that it has issued liability insurance covering bodily injury and property damage to
, (the "Insured"), of
Name of Insured
Address of Insured
in connection with the insured's obligation to demonstrate financial responsibility under 40 CFR 264.147 or
265.147, as adopted by reference in Section 62-730.180, Florida Administrative Code (F.A.C.). The coverage
applies at
EPA/DEP I.D. No.
Name
Address
for:
sudden accidental occurrences
nonsudden accidental occurrences
sudden and nonsudden accidental occurrences
If coverage is for multiple facilities and the coverage is different for different facilities, indicate which facility(ies) are insured for sudden
accidental occurrences, which are insured for nonsudden accidental occurrences, and which are insured for both.
The limits of liability are $
each occurrence and $
annual
aggregate, exclusive of legal defense costs. The coverage is provided under policy number
, issued on
. The effective date of said policy is
.
Date
Date
2. The Insurer further certifies the following with respect to the insurance described in Paragraph 1:
(a) Bankruptcy or insolvency of the insured shall not relieve the Insurer of its obligations under the
policy.
(b) The Insurer is liable for the payment of amounts within any deductible applicable to the policy, with
a right of reimbursement by the insured for any such payment made by the Insurer. This provision
does not apply with respect to that amount of any deductible for which coverage is demonstrated as
specified in 40 CFR 264.147(f) or 265.147(f), as adopted by reference in Section 62-730.180, F.A.C.
(c) Whenever requested by the Secretary of the Florida Department of Environmental Protection
(FDEP), the Insurer agrees to furnish to the Secretary a signed duplicate original of the policy and
all endorsements.
DEP FORM 62-730.900(4)(k)
Page 1 of 2
SAVE
PRINT
CLEAR
DEP Form # 62-730.900(4)(k)
Form Title HW Certificate of Liability Insurance
Effective Date January 5, 1995
DEP Application No.
STATE OF FLORIDA
HAZARDOUS WASTE FACILITY CERTIFICATE OF LIABILITY INSURANCE
(Primary Policy)
1.
,(the "Insurer"),
Name of Insurer
of
Address of Insurer
hereby certifies that it has issued liability insurance covering bodily injury and property damage to
, (the "Insured"), of
Name of Insured
Address of Insured
in connection with the insured's obligation to demonstrate financial responsibility under 40 CFR 264.147 or
265.147, as adopted by reference in Section 62-730.180, Florida Administrative Code (F.A.C.). The coverage
applies at
EPA/DEP I.D. No.
Name
Address
for:
sudden accidental occurrences
nonsudden accidental occurrences
sudden and nonsudden accidental occurrences
If coverage is for multiple facilities and the coverage is different for different facilities, indicate which facility(ies) are insured for sudden
accidental occurrences, which are insured for nonsudden accidental occurrences, and which are insured for both.
The limits of liability are $
each occurrence and $
annual
aggregate, exclusive of legal defense costs. The coverage is provided under policy number
, issued on
. The effective date of said policy is
.
Date
Date
2. The Insurer further certifies the following with respect to the insurance described in Paragraph 1:
(a) Bankruptcy or insolvency of the insured shall not relieve the Insurer of its obligations under the
policy.
(b) The Insurer is liable for the payment of amounts within any deductible applicable to the policy, with
a right of reimbursement by the insured for any such payment made by the Insurer. This provision
does not apply with respect to that amount of any deductible for which coverage is demonstrated as
specified in 40 CFR 264.147(f) or 265.147(f), as adopted by reference in Section 62-730.180, F.A.C.
(c) Whenever requested by the Secretary of the Florida Department of Environmental Protection
(FDEP), the Insurer agrees to furnish to the Secretary a signed duplicate original of the policy and
all endorsements.
DEP FORM 62-730.900(4)(k)
Page 1 of 2
(d)
Cancellation of the insurance, whether by the Insurer or the Insured, will be effective only upon
written notice and only after the expiration of sixty (60) days after a copy of such written notice
is received by the Secretary of the FDEP.
(e)
Any other termination of the insurance (e.g., expiration, non-renewal) will be effective only upon
written notice and only after the expiration of thirty (30) days after a copy of such written notice
is received by the Secretary of the FDEP.
I hereby certify that the wording of this instrument is substantially identical to the wording specified in
40 CFR 264.151(j), as adopted by reference in Section 62-730.180, F.A.C., as such regulation was constituted on
the date first above written, and that the Insurer is licensed to transact the business of insurance, or eligible to
provide insurance as an excess or surplus lines insurer, in one or more States including Florida.
Signature of Authorized Representative of Insurer
Type name
Title
Authorized Representative of
Name of Insurer
Address of Representative
DEP FORM 62-730.900(4)(k)
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