Each insurance policy must be amended by
an endorsement worded as specified in subdivision (b)(1) of this section, or
evidence by a certificate of insurance worded as specified in subdivision
(b)(2) of this section, except that instructions in brackets must be replaced
with the relevant information and the brackets deleted:
(1) Endorsement Name: [name of each covered
location]
____________________________________________________________________
____________________________________________________________________
Address: [address of each covered location]
____________________________________________________________________
____________________________________________________________________
Policy Number:
____________________________________________________________________
Period of Coverage: [current policy period]
____________________________________________________________________
Name of [Insurer or Risk Retention Group]:
____________________________________________________________________
Address of [Insurer or Risk Retention Group]:
____________________________________________________________________
____________________________________________________________________
Name of Insured:
____________________________________________________________________
Address of Insured:
____________________________________________________________________
____________________________________________________________________
Endorsement:
1. This endorsement certifies that the policy
to which the endorsement is attached provides liability insurance covering the
following USTs: [List the number of tanks at each facility and the name(s) and
address(es) of the facility(ies) where the tanks are located. If more than 1
instrument is used to assure different tanks at any 1 facility, for each tank
covered by this instrument, list the tank identification number provided in the
notification submitted pursuant to 40 C.F.R. part
280.22, or the corresponding
state requirement, and the name and address of the facility.] for [insert:
"taking corrective action" and/or "compensating third parties for bodily injury
and property damage caused by" either "sudden accidental releases" or non
sudden accidental releases" or "accidental releases" in accordance with and
subject to the limits of liability, exclusions, conditions, and other terms of
the policy; if coverage is different for different tanks or locations, indicate
the type of coverage applicable to each tank or location] arising from
operating the UST(s) identified above.
The limits of liability are [insert the dollar amount of
the "each occurrence" and "annual aggregate" limits of the Insurers or Groups
liability; if the amount of coverage is different for different types of
coverage or for different USTs or locations, indicate the amount of coverage
for each type of coverage and/or for each UST or location], exclusive of legal
defense costs, which are subject to a separate limit under the policy. This
coverage is provided under [policy number]. The effective date of said policy
is [date].
2. The insurance
afforded with respect to such occurrences is subject to all of the terms and
conditions of the policy; provided, however, that any provisions inconsistent
with subsections (a) to (e) of this Paragraph 2 are hereby amended to conform
with subsections (a) to (e);
a. Bankruptcy or
insolvency of the insured shall not relieve the ["Insurer" or "Group"] of its
obligations under the policy to which this endorsement is attached.
b. The ["Insurer" or "Group"] 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 the ["Insurer" or
"Group"]. 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 C.F.R. parts
280.95-280.102 and
280.104-280.107.
c. Whenever
requested by [a Director of an implementing agency], the ["Insurer" or "Group"]
agrees to furnish to [the Director] a signed duplicate original of the policy
and all endorsements.
d.
Cancellation or any other termination of the insurance by the ["Insurer" or
"Group"] except for nonpayment 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 1 days after a copy of such written notice is received by the
insured.
[Insert for claims made policies:
e. The insurance covers claims otherwise
covered by the policy that are reported to the ["Insured" or "Group"] within 6
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.]
I hereby certify that the wording of this instrument is
identical to the wording in 40 C.F.R. part 280.97(b)(1) and that the ["Insurer"
or "Group"] is ["licensed to transact the business or insurance or eligible to
provide insurance as an excess or surplus lines insurer in 1 or more
states".]
[Signature of authorized representative of Insurer or
Risk Retention Group]
____________________________________________________________________
[Name of person signing]
____________________________________________________________________
[Title of person signing], Authorized Representative of
[name of Insurer or Risk Retention Group]
____________________________________________________________________
[Address of Representative]
____________________________________________________________________
____________________________________________________________________
(2)
Certificate of Insurance
Name: [name of each covered location]
____________________________________________________________________
Address: [address of each covered location]
____________________________________________________________________
Policy Number:
____________________________________________________________________
Endorsement (if applicable):
____________________________________________________________________
Period of Coverage: [current policy period] Name of
[Insurer or Risk Retention Group]:
____________________________________________________________________
Address of [Insurer or Risk Retention Group]:
____________________________________________________________________
Name of Insured:
____________________________________________________________________
Address of Insured:
____________________________________________________________________
____________________________________________________________________
Certification:
1. [Name of Insurer or Risk Retention Group],
[the "Insurer" or "Group"], as identified above, hereby certifies that it has
issued liability insurance covering the following UST(s): [List the number of
tanks at each facility and the name(s) and address(es) of the facility(ies)
where the tanks are located. If more than 1 instrument is used to assure
different tanks at any 1 facility, for each tank covered by this instrument,
list the tank identification number provided in the notification submitted
pursuant to 40 C.F.R. part
280.22, or the corresponding state requirement, and
the name and address of the facility.] for [insert: "taking corrective action"
and/or "compensating third parties for bodily injury and property damage caused
by" either "sudden accidental releases" or "nonsudden accidental releases" or
"accidental releases" in accordance with and subject to the limits of
liability, exclusions, conditions, and other terms of the policy; if coverage
is different for different tanks or locations, indicate the type of coverage
applicable to each tank or location] arising from operating the UST(s)
identified above.
The limits of liability are [insert the dollar amount of
the "each occurrence" and "annual aggregate" limits of the Insurers or Groups
liability; if the amount of coverage is different for different types of
coverage or for different USTs or locations, indicate the amount of coverage
for each type of coverage and/or for each UST or location], exclusive of the
legal defense costs, which are subject to a separate limit under the policy.
This coverage is provided under [policy number]. The effective date of said
policy is [date].
2. The
["Insurer" or "Group"] 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" or
"Group"] of its obligations under the policy to which this certificate
applies.
b. The ["Insurer" or
"Group"] 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 the
[Insurer" or "Group"]. 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 C.F.R. parts
280.95
to 280.102 and 280.104 to 280.107.
c. Whenever requested by [a Director of an
implementing agency], the ["Insurer" or "Group"] agrees to furnish to [the
Director] a signed duplicate original of the policy and all
endorsements.
d. Cancellation or
any other termination of the insurance by the ["Insurer" or "Group"] except for
not-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.
[Insert for claims-made policies:
e. The insurance covers claims otherwise
covered by the policy that are reported to the ["Insurer" or "Group"] within 6
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.]
I hereby certify that the wording of this instrument is
identical to the wording in 40 C.F.R. part 280.97(b)(2) and that the ["Insurer"
or "Group"] is ["licensed to transact the business of insurance or eligible to
provide insurance as an excess or surplus lines insurer, in 1 or more
states"].
[Signature of authorized representative of
Insurer]
[Type Name]
[Title], Authorized Representative of [name of Insurer or
Risk Retention Group]
[Address of Representative]
