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
[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 one instrument is used to assure different tanks at any one facility, for each tank covered by this instrument, list the tank identification number provided in the registration submitted pursuant to LAC 33:XI.301 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"; if coverage is different for different tanks or locations, indicate the type of coverage applicable to each tank or location] arising from operating the underground storage tank(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 underground storage tanks or locations, indicate the amount of coverage for each type of coverage and/or for each underground storage tank or location], exclusive of legal defense costs. This coverage is provided under [policy number]. The effective date of said policy is [date].
[Insert for claims-made policies:
I hereby certify that the wording of this instrument is identical to the wording in LAC 33:XI.1115.B.1 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"].
[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]
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
[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 one instrument is used to assure different tanks at any one facility, for each tank covered by this instrument, list the tank identification number provided in the registration submitted pursuant to LAC 33:XI.301 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"; if coverage is different for different tanks or locations, indicate the type of coverage applicable to each tank or location] arising from operating the underground storage tank(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 underground storage tanks or locations, indicate the amount of coverage for each type of coverage and/or for each underground storage tank or location], exclusive of legal defense costs. This coverage is provided under [policy number]. The effective date of said policy is [date].
[Insert for claims-made policies:
I hereby certify that the wording of this instrument is identical to the wording in LAC 33:XI.1115.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 one or more states"].
[Signature of authorized representative of insurer]
[Typed name]
[Title], authorized representative of [name of insurer or risk retention group]
[Address of representative]
La. Admin. Code tit. 33, § XI-1115