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 notification submitted pursuant to 40 CFR 280.22, or the corresponding state requirement, 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 ARM 17.56.809(2)(a) 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 notification submitted pursuant to 40 CFR 280.22, or the corresponding state requirement, 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 ARM 17.56.809(2)(b) 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]
[Type name]
[Title], Authorized Representative of [name of Insurer or Risk Retention Group]
[Address of Representative]
Mont. Admin. r. 17.56.809
AUTH: 75-11-505, MCA; IMP: 75-11-505, MCA