Fillable Printable Certificate of Insurance Form - Virginia

Certificate of Insurance Form - Virginia

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***** CERTIFICATE OF INSURANCE *****

To the Virginia Department of Agriculture and Consumer Services:

I hereby certify that Policy # _______________________ provides coverage, in the

form of a general liability policy from a person authorized to do business in

Virginia or a certification thereof, protecting persons who may suffer legal

damages as a result of the use of any pesticide by the applicant. This policy is

in a minimum of:

$____________ for property damage, $____________ for personal injury and

$____________ per occurrence.

$____________ deductible amount (see reverse for deductible requirements)

Exclusions (please specify): ________________________________________________

This policy has been issued to:

(Name of Insured) (Address)

(Trading As, or D.B.A.) (Address)

Policy term:

Effective date: _____________ Expiration date: _____________

In the event of cancellation, the insurer agrees to advise the VDACS Office of

Pesticide Services, by written notice, at least 10 days prior to the effective

date of cancellation.

(Insurance Company Providing Coverage)

(Agency Issuing Policy) (Company Seal or Stamp)

(Street) (City) (State) (Zip)

___________________________________________ ____________________________

(Signature - Authorized Representative) (Date of Certificate)

For acceptance by the Virginia Department of Agriculture and Consumer Services,

this form must be properly completed, validated and signed by the issuing

insurance agency. Mail completed certificate to the address below.

Certificate Holder:Office of Pesticide Services

Virginia Department of Agriculture and Consumer Services

P. O. Box 1163

Richmond, Virginia 23218

4-5-96 (see reverse side) VDACS-07214

EVIDENCE OF FINANCIAL RESPONSIBILITY REQUIRED OF

A LICENSED PESTICIDE BUSINESS

DEFINITION: "Pesticide business" means any person engaged in the business of

distributing, applying or recommending the use of a product; or storing, selling,

or offering for sale pesticides directly to the user. The term "pesticide

business" does not include (I) wood treaters not for hire; (ii) seed treaters not

for hire; (iii) operations which produce agricultural products unless the owners

or operators of such operations described in clauses (I), (ii), and (iii) are

engaged in the business of selling or offering for sale pesticides, or

distributing pesticides to persons outside of that agricultural producing

operations in connection with commercial transactions; or (iv) businesses exempted

by regulations adopted by the Board.

Prior to being issued a pesticide business license, a business shall furnish

evidence of financial responsibility consisting of a liability insurance policy,

or certification thereof, protecting persons who may suffer legal damages as a

result of the use of any pesticides by the applicant. Such financial

responsibility need not apply to damages or injury to agricultural crops, plants

or property being worked upon by the applicant.

Minimum Insurance Requirements

$100,000 for property damage

$100,000 for personal injury and $300,000 per occurrence.

A deductible clause in an amount which is usual and customary in the

industry, with the provision that the insurer shall pay all claims in full and

that the amount of the deductible shall be recoverable only from the insured, may

be accepted.

The business licensee shall maintain at least the minimum coverage at all times

during the license period, and shall provide a current certificate of insurance

to the Office of Pesticide Services at each insurance renewal date.

Note - This certificate is for use only in providing proof of liability insurance

coverage.

Revised form - This form supersedes all previous certificate of insurance forms

issued by the VDACS Office of Pesticide Services.