Department of Natural Resources and Environmental Control
Tank Management Section
1351 Underground Storage Tank Systems
Authenticated PDF VersionName: __________________________________________
[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: ____________________________________________________________
______________________________________________________________________
______________________________________________________________________
1. [Name of the Insurer or Risk Retention Group], the "insurer" or "Group," as identified above, hereby certifies that it has issued liability insurance covering the following Underground Storage Tank Systems:
Attach Appendix R, Tank Schedule, listing each UST System assured by this Insurance Policy.
For [insert: "taking corrective action" and/or "compensating third parties for Bodily Injury and Property Damage"] caused by 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 System(s) identified above).
The limits of liability are [insert the dollar amount of the "each Occurrence" and "Annual Aggregate" limits of the Insurer's or Group's liability]; (if the amount of coverage is different for different types of coverage or for different UST System(s) or locations, indicate the amount of coverage for each type of coverage and/or for each UST System or location), exclusive of Legal Defense Costs which are subject to separate limits under the policy. This coverage is provided under [Policy Number]. The effective date of said policy is [date].
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 Part F, §§2.2 through 2.12 of the Delaware Regulations Governing Underground Storage Tank Systems.
c. Whenever requested by the Department, the ["Insurer" or "Group"] agrees to furnish to the Department 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 non-payment of premium or misrepresentation by the insured shall 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.
e. [Insert for claims-made policies:
The insurance covers claims otherwise covered by the policy that are reported to the ["Insurer" or "Group"] within six months of the effective date of the 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 Part F, §3.4 Form D of the Delaware Regulations Governing Underground Storage Tank Systems 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 one or more States."]
______________________________________________________________________
[Date]
______________________________________________________________________
[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]
