Form AGR640-4179 "Structural Pest Inspector Financial Responsibility Insurance Certificate - Option 1" - Washington

What Is Form AGR640-4179?

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 October 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 AGR640-4179 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 AGR640-4179 "Structural Pest Inspector Financial Responsibility Insurance Certificate - Option 1" - 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 1
Olympia, WA 98504-2560
FINANCIAL RESPONSIBILITY
Toll Free 877-301-4555
FAX (360) 902-2093
INSURANCE CERTIFICATE (FRIC)
E-Mail: license@agr.wa.gov
Instructions: Washington pesticide law (Chapter 15.58 RCW) requires that Structural Pest Inspectors (SPIs) or the companies
that employ them provide proof of financial coverage. See http://agr.wa.gov/PestFert/LicensingEd/CaSpiInfo.htm for an
explanation of the four options available. Use this form to report Option 1. DO NOT use this form to report a claims made
insurance policy!
Important: This form is for 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.
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 the insurance meets the conditions of RCW 15.58.465(1)(a). 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. However, the policy may limit the insurer’s liability
on the policy in effect at the time of the inspection to two years from the date of the inspection.
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 _________________________________________________________
Does this policy meet the requirements of
NAME AND ADDRESS OF LOCAL AGENT
RCW 15.58.465(1)(a) (see above) ?
Yes
Note: Claims made insurance policies DO NOT meet this requirement.
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 640-4179 (R/10/03)
Washington State Department of Agriculture
STRUCTURAL PEST INSPECTOR
Pesticide Management Division
P.O. Box 42560
PROOF OF FINANCIAL COVERAGE –
OPTION 1
Olympia, WA 98504-2560
FINANCIAL RESPONSIBILITY
Toll Free 877-301-4555
FAX (360) 902-2093
INSURANCE CERTIFICATE (FRIC)
E-Mail: license@agr.wa.gov
Instructions: Washington pesticide law (Chapter 15.58 RCW) requires that Structural Pest Inspectors (SPIs) or the companies
that employ them provide proof of financial coverage. See http://agr.wa.gov/PestFert/LicensingEd/CaSpiInfo.htm for an
explanation of the four options available. Use this form to report Option 1. DO NOT use this form to report a claims made
insurance policy!
Important: This form is for 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.
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 the insurance meets the conditions of RCW 15.58.465(1)(a). 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. However, the policy may limit the insurer’s liability
on the policy in effect at the time of the inspection to two years from the date of the inspection.
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 _________________________________________________________
Does this policy meet the requirements of
NAME AND ADDRESS OF LOCAL AGENT
RCW 15.58.465(1)(a) (see above) ?
Yes
Note: Claims made insurance policies DO NOT meet this requirement.
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 640-4179 (R/10/03)