Form AGR640-4189 "Structural Pest Inspector Financial Responsibility Insurance Certificate - Option 3" - Washington

What Is Form AGR640-4189?

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

Form Details:

  • Released on June 1, 2003;
  • The latest edition provided by the Washington State Department of Agriculture;
  • 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 printable version of Form AGR640-4189 by clicking the link below or browse more documents and templates provided by the Washington State Department of Agriculture.

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Download Form AGR640-4189 "Structural Pest Inspector Financial Responsibility Insurance Certificate - Option 3" - Washington

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Washington State Department of Agriculture
STRUCTURAL PEST INSPECTOR
Pesticide Management Division
P.O. Box 42560
PROOF OF FINANCIAL COVERAGE –
OPTION 3*
Olympia, WA 98504-2560
FINANCIAL RESPONSIBILITY
Toll Free 877-301-4555
FAX (360) 902-2093
INSURANCE CERTIFICATE (FRIC)
E-Mail: license@agr.wa.gov
*Option 3 requires an insurance policy and a surety bond. See instructions.
Important: This form is for Structural Pest Inspectors (SPIs) who perform wood destroying organism inspections. It is NOT
the form used by Commercial Applicators (CAs) to report financial coverage for the company’s pesticide applications!
CAs who perform complete wood destroying organism (WDO) inspections must meet the financial coverage
requirements of that license AND the Structural Pest Inspector. Licensees with current CA insurance, and their
Commercial Operator employees, do not need to meet the SPI financial coverage requirement when performing
specific WDO inspections. Complete WDO inspections are done for the purpose of determining evidence of
infestation, damage, or conducive conditions as part of the transfer, exchange, or refinancing of any structure. Specific
WDO inspections are those done for the purpose of identifying or verifying evidence of an infestation of WDOs
prior to pest management activities.
Instructions: Washington pesticide law (Chapter 15.58 RCW) requires that SPIs or the companies that employ them provide
proof of financial coverage. Use this form to report the insurance policy portion of Option 3. This option also requires
a surety bond in the amount of $12,500. See http://agr.wa.gov/PestFert/LicensingEd/CaSpiInfo.htm for further information
on this bond requirement, including the surety bond form, and an explanation of the other options available.
Agent Information: This form is only valid when completed by an Insurance Agent. For new licenses, this form must be
submitted BEFORE the SPI license can be issued. For existing licenses, it must be submitted by the expiration date of the
inspector’s insurance policy or the SPI license is automatically suspended.
By signing this form, the agent verifies that this policy meets the insurance requirement of RCW 15.58.465(1)(c). This
requires an errors and omissions insurance policy of not less than twenty-five thousand dollars that is maintained at or above the
required sum at all times during the licensed period. The maximum deductible is $5,000. The insurance policy shall provide
coverage for errors and omissions in an inspection conducted during the term of the policy.
The following described Insurance Policy has been issued and is in full force and effect as set forth below:
NAME AND ADDRESS OF PEST INSPECTION COMPANY (POLICY HOLDER)
NAME OF INSURANCE COMPANY
POLICY NUMBER
NAME OF PRIMARY LICENSEE __________________________________________________
LIMIT OF COVERAGE
(
)
TELEPHONE NUMBER _________________________________________________________
NAME AND ADDRESS OF LOCAL AGENT
Does this policy meet the requirements of
RCW 15.58.465(1)(c) (see above) ?
Yes
DEDUCTIBLE
POLICY PERIOD:
(
)
TELEPHONE NUMBER _________________________________________________________
FROM:
TO:
It is agreed that the company will file with the Department of Agriculture WITHIN TEN DAYS copies of any and all endorsements
extending, restricting, changing, cancelling or renewing the aforementioned coverage. Whenever requested by the Department,
the company agrees to furnish a copy of said policy and all endorsements thereon. Please notify the Department if this client
fails to meet the deductible clause in any legal claim.
I certify that I have legal authority to act for ____________________________________________ ; that said company is
a direct representative of the Underwriters and not a local agent; and that said company is qualified to do business in the state
of Washington; and that the insurance coverage is placed through a properly licensed agent in Washington.
Authorized Agent (please print): _______________________________________________________________________
Signature: ___________________________________________________
Date: ___________________________
NOTE: Return to the Department of Agriculture at the address or fax number above.
AGR 640-4189 (N/6/03)
Washington State Department of Agriculture
STRUCTURAL PEST INSPECTOR
Pesticide Management Division
P.O. Box 42560
PROOF OF FINANCIAL COVERAGE –
OPTION 3*
Olympia, WA 98504-2560
FINANCIAL RESPONSIBILITY
Toll Free 877-301-4555
FAX (360) 902-2093
INSURANCE CERTIFICATE (FRIC)
E-Mail: license@agr.wa.gov
*Option 3 requires an insurance policy and a surety bond. See instructions.
Important: This form is for Structural Pest Inspectors (SPIs) who perform wood destroying organism inspections. It is NOT
the form used by Commercial Applicators (CAs) to report financial coverage for the company’s pesticide applications!
CAs who perform complete wood destroying organism (WDO) inspections must meet the financial coverage
requirements of that license AND the Structural Pest Inspector. Licensees with current CA insurance, and their
Commercial Operator employees, do not need to meet the SPI financial coverage requirement when performing
specific WDO inspections. Complete WDO inspections are done for the purpose of determining evidence of
infestation, damage, or conducive conditions as part of the transfer, exchange, or refinancing of any structure. Specific
WDO inspections are those done for the purpose of identifying or verifying evidence of an infestation of WDOs
prior to pest management activities.
Instructions: Washington pesticide law (Chapter 15.58 RCW) requires that SPIs or the companies that employ them provide
proof of financial coverage. Use this form to report the insurance policy portion of Option 3. This option also requires
a surety bond in the amount of $12,500. See http://agr.wa.gov/PestFert/LicensingEd/CaSpiInfo.htm for further information
on this bond requirement, including the surety bond form, and an explanation of the other options available.
Agent Information: This form is only valid when completed by an Insurance Agent. For new licenses, this form must be
submitted BEFORE the SPI license can be issued. For existing licenses, it must be submitted by the expiration date of the
inspector’s insurance policy or the SPI license is automatically suspended.
By signing this form, the agent verifies that this policy meets the insurance requirement of RCW 15.58.465(1)(c). This
requires an errors and omissions insurance policy of not less than twenty-five thousand dollars that is maintained at or above the
required sum at all times during the licensed period. The maximum deductible is $5,000. The insurance policy shall provide
coverage for errors and omissions in an inspection conducted during the term of the policy.
The following described Insurance Policy has been issued and is in full force and effect as set forth below:
NAME AND ADDRESS OF PEST INSPECTION COMPANY (POLICY HOLDER)
NAME OF INSURANCE COMPANY
POLICY NUMBER
NAME OF PRIMARY LICENSEE __________________________________________________
LIMIT OF COVERAGE
(
)
TELEPHONE NUMBER _________________________________________________________
NAME AND ADDRESS OF LOCAL AGENT
Does this policy meet the requirements of
RCW 15.58.465(1)(c) (see above) ?
Yes
DEDUCTIBLE
POLICY PERIOD:
(
)
TELEPHONE NUMBER _________________________________________________________
FROM:
TO:
It is agreed that the company will file with the Department of Agriculture WITHIN TEN DAYS copies of any and all endorsements
extending, restricting, changing, cancelling or renewing the aforementioned coverage. Whenever requested by the Department,
the company agrees to furnish a copy of said policy and all endorsements thereon. Please notify the Department if this client
fails to meet the deductible clause in any legal claim.
I certify that I have legal authority to act for ____________________________________________ ; that said company is
a direct representative of the Underwriters and not a local agent; and that said company is qualified to do business in the state
of Washington; and that the insurance coverage is placed through a properly licensed agent in Washington.
Authorized Agent (please print): _______________________________________________________________________
Signature: ___________________________________________________
Date: ___________________________
NOTE: Return to the Department of Agriculture at the address or fax number above.
AGR 640-4189 (N/6/03)