Fillable Printable Certificate of Liability Insurance Form - Kansas
Fillable Printable Certificate of Liability Insurance Form - Kansas
Certificate of Liability Insurance Form - Kansas
Form KPL 410NA (rev 10/2012)
(Guidelines for completion follo w)
CERTIFICATE OF LIABILITY INSURANCE
FOR NON-AER IAL APPLIC ATOR S
This is to certify that we have issued a business liability insurance policy to:
KS Pesticide Business Lic. #
Policy Number
Effective Date
Expiration Date
Name of Insured Pesticide Business
Doing business as name (d/b/a)
Ma iling Addr ess
City
State
ZIP
Location Address
City
State
ZIP
The insur ance l iability coverage h er ein pertains to the use of pesticides, and is separate from, or in
addition to any c o verage of business vehicles.
The undersigned here by certif ies that liabilit y ins urance issued to the a bove nam ed pestic ide bus iness, f ulfills the
requirements of K.S.A. 2-2448 as amended and supplemented and affords the following coverage:
(1) Coverage for not less than $5,000 per occurrence property damage liability for damages to real or personal
property that suffer damage as a result of the use of pesticides by the pesticide business or persons working
under the super visi on of s uc h bus ines s . Co verage must be pro v ide d to c over “pr o per t y damage” r egar dles s o f the
premises, site or location at which or on which the pesticide use or damage occurred. Property damage
deductible $__________.
(2) Coverage for not less than $25,000 per occurrence bodily injury liability for injuries to persons not employed by
the pesticide business, that suffer injury as a result of the use of pesticides by the pesticide business or persons
work ing under the s uper vision of suc h busi ness . Cover age m ust be pro vided to co ver “b odil y inj ury” re gard less of
the premises, site or location at which or on which the pesticide use or injury occurred. Bodily injury deductible
$__________.
Liability insurance provided in accordance with the above numbered policy is subject to the insurance policy
provisions of the com pany filed with and approved by the Kansas Commissioner of Insurance pursuant to K.S.A.
40-216 except as authorized by K.S.A. 40-246b.
The insurer agrees to provide written notification to the Secretary, Kansas Department of Agriculture, at least 10
days prior to the effective date of any expiration, reduction or cancellation of the liability insurance. Such
notification is to be sent to: Kansas Department of Agriculture, Records Center, Business Licensing Section, 109
SW 9
th Street, Topeka, KS 66612. Fax 785-296-6418. Ph 785-296-5210
Name of Insurance Company
Address
City
State
Zip
Authorized Ins. Representative’s Signature
Date
Telephone Number
Guidelines
Certificate of Liability for Non-Aerial Applicators
These guidelines are provided to help in the preparation and submission of acceptable insurance certificates. If these
guidelines are followed, it will result in more expeditious handling of insurance certificate matters in connection with
Kansas pesticide applicator business license requirements.
The certificate of liability insurance is supplied to you for your use and convenience in meeting licensing requirements
as a non-aerial applicator; however, the certificate of liability insurance does not have to be on this particular form. No
matter w hat form is used the following is required:
1. Non-Aerial Applic ators
a. The insurance coverage must cover damages caus ed by any pesticides used by the business as follows:
1. For not less than $5,000 per occurrence property damage liability for damages to real or personal property, that
suffer damage as a result of the use of pesticides by the pesticide business or persons working under the supervision of
such business. Coverage must be provided to cover “property damage” regardless of the premises, site or location at
which or on which the pesticide use or damage occurred.
2.For not less than $25,000 per occurrence bodily injury liability for injuries to persons not employed by the pesticide
business that suffer injury as a result of the use of pesticides by the pestic ide business or persons working under the
supervision of such business. Coverage must by provided to cover “bodily injury” regardless of the premises, site or
location at which or on which the pesticide use or injury occurred.
b. K.S.A. 2-2438a(n) defines “pesticides” as, “(1) any substance or mixture of s ubstances used to prevent, destroy,
control repel, attract or mitigate any pest and (2) any substance or mixture of substances intended to be used as a plant
regulator, defoliant or desiccant.”
2. If the insurance policy specifically excludes a particular pesticide or method of application, the business may not use
that pesticide or method of application.
3. To be timely processed, the following information must be included on the certificate of insurance:
The policy number;
The policy’s effective date;
The policy’s ex piration date;
The signature (handwritten or stamped) of an authorized representative of the insurance company;
The insurance company’s name, address and tel ephone number;
The insured’s complete legal name;
The name under which the insured does business (d/b/a); and
The insured’s Pesticide Business License number.
4. The certificate of liability insurance must be executed by an insurance company authorized to do business in Kansas
or by a licensed insurance agent operating under authority of K.S.A. 40-246b.
5. NOTICE TO INSURANCE COMPANY - If you do not currently have on file with the Kansas Insurance Department an
Endorsement permitting you to notify the Secretary, Kansas Department of Agriculture, of the expiration, reduction or
cancellation of the insured’s policy, please file such endorsement immediately pursuant to K.S.A. 40-216.
The endorsement should read:
In compliance with K.S.A. 2-2448 as amended and supplemented, the company hereby agrees to notify the Secretary,
Kansas Department of Agriculture, in writing, of any expiration, reduction or cancellation of this policy at least 10 days
prior to the effective date of such expiration, reduction or cancellation.
In order that companies will not be in violation of insurance laws, each company must file with the Insurance
Commissioner a copy of the endorsement they put on policies.
6. Return the completed Certific ate of Liability Insurance to: KANSAS DEPARTMENT OF AGRICULTURE
Records Center-Business Licensing Section
109 SW 9th St
Topeka, Ks 66612-1281
