329 Ind. Admin. Code 3.1-14-30
Authority: IC 13-14-8; IC 13-22-2; IC 13-22-8-1; IC 13-22-9-7
Affected: IC 13-22
Sec. 30.
A certificate of insurance, as specified in section 8 or 18 of this rule, 329 IAC 3.1-15-4(f), or 329 IAC 3.1-15-6(f), 329 IAC 3.1-15-10(e)) , must be worded as follows except that instructions in brackets are to be replaced with the relevant information and the brackets deleted:
Certificate of Insurance for Corrective Action, Closure, or Post-Closure Care
Name and Address of Insurer (herein called the "Insurer"): ______________________
Name and Address of Insured (herein called the "Insured"): ______________________
Facilities Covered: [List for each facility: the U.S. EPA identification number, name, address, and the amount of insurance for corrective action, closure, and/or the amount for post-closure. (These amounts for all facilities covered must total the face amount shown below.)]
Face Amount: __________________________________________________
Policy Number: _________________________________________________
Effective Date: __________________________________________________
The Insurer hereby certifies that it has issued to the Insured the policy of insurance identified above to provide financial assurance for [insert "corrective action", "closure", and/or "post-closure care"] for the facilities identified above. The Insurer further warrants that such policy conforms in all respects with the requirements of 329 IAC 3.1-14-8, 329 IAC 3.1-14-18, 329 IAC 3.1-15-4(f), or 329 IAC 3.1-15-6(f) 329 IAC 3.1-15-10(e)) as applicable and as such regulations were constituted on the date shown immediately below. It is agreed that any provision of the policy inconsistent with such regulations is hereby amended to eliminate such inconsistency.
Whenever requested by the Indiana Department of Environmental Management (IDEM) commissioner, the Insurer agrees to furnish to the IDEM commissioner a duplicate original of the policy listed above including all endorsements thereon.
I hereby certify that the wording of this certificate is identical to the wording specified in 329 IAC 3.1-14-30 as such rule was constituted on the date shown immediately below.
[Authorized signature for Insurer]
[Name of person signing]
[Title of person signing]
Signature of witness or notary: ____________________________________
[Date]
329 IAC 3.1-14-30