(NOTE: Instructions in brackets are to be replaced with the relevant information and the brackets deleted.)
ENDORSEMENT FOR LIABILITY COVERAGE.
Attached to and forming part of policy No. ______ issued by [name of Insurer], herein called the Insurer, of [address of Insurer] to [name of insured] of [address] this ____ day of ______, 20__. The effective date of said policy is ____ day of ______, 20__.
I hereby certify that the wording of this endorsement is identical to the wording specified in the relevant regulations of the Department of Environmental Quality, Commonwealth of Virginia, and that the Insurer 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]
[Address of Representative]
SCHEDULE A
IDENTIFICATION OF COVERED VESSELS
Insurance Policy [insert policy number] is applicable to the following vessels:
Vessel Name Gross tons Owner Operator
9 Va. Admin. Code § 20-170-400:4
Statutory Authority
§§ 10.1-1402 and 10.1-1454.1 of the Code of Virginia.