DEP Form 62-761.900(3) Part D "Storage Tank Certificate of Insurance" - Florida

What Is DEP Form 62-761.900(3) Part D?

This is a legal form that was released by the Florida Department of Environmental Protection - a government authority operating within Florida.The document is a supplement to DEP Form 62-761.900(3), Storage Tank Certificate of Insurance. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on October 1, 2019;
  • 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 62-761.900(3) Part D 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 62-761.900(3) Part D "Storage Tank Certificate of Insurance" - Florida

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DEP Form 62-761.900(3) Part D
Form Title: Financial Mechanisms for Storage Tanks
A copy of financial instruments kept off-site shall be made
Part D: ST Certificate of Insurance
available for inspection upon five business days notice.
Form Effective Date October 2019
Incorporated in Rules 62-761.420 and 62-762.421, F.A.C.
STATE OF FLORIDA
STORAGE TANK CERTIFICATE OF INSURANCE
Reference: 40 CFR 280.97(b)(2)
Insurance Company or Risk Retention Group:
FL insurance companies
, (herein referred to as “Insurer”),
[Name of insurance company or risk retention group]
[Business address of Insurer]
Insurer is a(n)
.
[Enter "insurance company" or "risk retention group"]
Insured:
Sunbiz
[Name of owner or operator]
[Business address of owner or operator]
Policy Number:
Endorsement Number:
[If applicable]
Period of Coverage:
Policy Effective Date:
[Current policy period]
Covered Locations:
[List information for each facility. See Instruction #6 on page i for details. Indicate “See attachment” if required.]
FDEP FacID
Facility Name and Site Address
Number of Tanks
(for sites in Florida)
(for all sites covered)
or Tank I.D. Nos.
Certification:
1. Insurer hereby certifies that it has issued to the Insured the liability insurance identified above to provide financial
assurance for
[Insert "taking corrective action" and/or "compensating third parties for bodily injury and property damage caused by"]
in accordance with and subject to the limits of
[Insert “accidental discharges” or “sudden accidental discharges” or “nonsudden
accidental discharges” or leave blank if only corrective action is covered]
liability, exclusions, conditions, and other terms of the policy arising from operating the facilities/tanks identified above. The
Insurer further warrants that such policy conforms in all respects with the requirements of Rule(s) 62-761.420 and/or
62-762.421, Florida Administrative Code (F.A.C.), as applicable, which adopt 40 CFR Part 280 Subpart H by reference,
for the above specified financial assurance. It is agreed that any provision of the policy inconsistent with such regulations
is hereby amended to eliminate such inconsistency.
Part D page 1 of 2
DEP Form 62-761.900(3)
Entire form page 10 of 42
SAVE
PRINT
CLEAR
DEP Form 62-761.900(3) Part D
Form Title: Financial Mechanisms for Storage Tanks
A copy of financial instruments kept off-site shall be made
Part D: ST Certificate of Insurance
available for inspection upon five business days notice.
Form Effective Date October 2019
Incorporated in Rules 62-761.420 and 62-762.421, F.A.C.
STATE OF FLORIDA
STORAGE TANK CERTIFICATE OF INSURANCE
Reference: 40 CFR 280.97(b)(2)
Insurance Company or Risk Retention Group:
FL insurance companies
, (herein referred to as “Insurer”),
[Name of insurance company or risk retention group]
[Business address of Insurer]
Insurer is a(n)
.
[Enter "insurance company" or "risk retention group"]
Insured:
Sunbiz
[Name of owner or operator]
[Business address of owner or operator]
Policy Number:
Endorsement Number:
[If applicable]
Period of Coverage:
Policy Effective Date:
[Current policy period]
Covered Locations:
[List information for each facility. See Instruction #6 on page i for details. Indicate “See attachment” if required.]
FDEP FacID
Facility Name and Site Address
Number of Tanks
(for sites in Florida)
(for all sites covered)
or Tank I.D. Nos.
Certification:
1. Insurer hereby certifies that it has issued to the Insured the liability insurance identified above to provide financial
assurance for
[Insert "taking corrective action" and/or "compensating third parties for bodily injury and property damage caused by"]
in accordance with and subject to the limits of
[Insert “accidental discharges” or “sudden accidental discharges” or “nonsudden
accidental discharges” or leave blank if only corrective action is covered]
liability, exclusions, conditions, and other terms of the policy arising from operating the facilities/tanks identified above. The
Insurer further warrants that such policy conforms in all respects with the requirements of Rule(s) 62-761.420 and/or
62-762.421, Florida Administrative Code (F.A.C.), as applicable, which adopt 40 CFR Part 280 Subpart H by reference,
for the above specified financial assurance. It is agreed that any provision of the policy inconsistent with such regulations
is hereby amended to eliminate such inconsistency.
Part D page 1 of 2
DEP Form 62-761.900(3)
Entire form page 10 of 42
The limits of liability are:
Each Occurrence: $
Annual Aggregate: $
[If the amount of coverage is different for different types of coverage or for different storage tanks or locations, indicate on the facility list above or by
separate attachment the amount of coverage for each type of coverage and/or for each storage tank or location.]
exclusive of legal defense costs, which are subject to a separate limit under the policy.
2. Insurer further certifies the following with respect to this policy:
(a) Bankruptcy or insolvency of the insured shall not relieve Insurer of its obligations under the policy to which this
certificate applies.
(b) Insurer is liable for the payment of amounts within any deductible applicable to the policy to the provider of
corrective action or a damaged third-party, with a right of reimbursement by the insured for any such payment
made by Insurer. This provision does not apply with respect to that amount of any deductible for which coverage
is demonstrated under another mechanism or combination of mechanisms as specified in
40 CFR 280.95 - 280.102 and 280.104 - 280.107.
(c) Whenever requested by the Florida Department of Environmental Protection (FDEP) Secretary or the Secretary's
designee ("designee"), Insurer agrees to furnish, to the FDEP Secretary or designee, a signed duplicate original
of the policy and all endorsements.
(d) Cancellation or any other termination of the insurance by Insurer except for non-payment of premium or
misrepresentation by the insured, will be effective only upon written notice and only after the expiration of 60 days
after a copy of such written notice is received by the insured. Cancellation for non-payment of premium or
misrepresentation by the insured will be effective only upon written notice and only after expiration of a minimum
of 10 days after a copy of such written notice is received by the insured.
(e) Policy does not include choice of law and venue in favor of jurisdictions other than Florida.
[Check here if the following paragraph, for claims-made policies, applies.]
(f) The insurance covers claims otherwise covered by the policy that are reported to Insurer within six months of the
effective date of cancellation or non-renewal of the policy except where the new or renewed policy has the same
retroactive date or a retroactive date earlier than that of the prior policy, and which arise out of any covered
occurrence that commenced after the policy retroactive date, if applicable, and prior to such policy renewal or
termination date. Claims reported during such extended reporting period are subject to the terms, conditions,
limits, including limits of liability, and exclusions of the policy.
The person whose signature appears below hereby certifies that the wording of this instrument is identical to the wording
as adopted and incorporated by reference in Rule(s) 62-761.420 and/or 62-762.421, F.A.C., and that Insurer is
.
[Insert "licensed to transact the business of insurance” or “eligible to provide insurance as an excess or surplus lines insurer in Florida"]
Authority to amend policy, pursuant to paragraph 1.,
[Signature of Authorized Representative of Insurer]
is substantiated by
:
[Select at least one]
embossed seal of Insurer
[Name and Title]
electronic seal of Insurer
signature is of Insurer's President
signature matches signature on policy
[Address]
accompanying letter from Insurer’s President
verifies signatory has authority to amend policies
[Telephone Number]
[Email Address]
[Date of Witness or Notary]
[Signature of Witness or Notary]
[Printed Name of Witness or include Notary Seal]
Part D page 2 of 2
DEP Form 62-761.900(3)
Entire form page 11 of 42
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