Dep Form 62-730.900(5)(A)- State Of Florida Certificate Of Liability Insurance Hazardous Waste Transporter And Used Oil Handler

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Mail original completed form to:
Department of Environmental Protection
For assistance call: 850-245-8707
2600 Blair Stone Road, Mail Station 4560
Tallahassee, Florida 32399-2400
STATE OF FLORIDA
CERTIFICATE OF LIABILITY INSURANCE
HAZARDOUS WASTE TRANSPORTER AND USED OIL HANDLER
1.
_____________________________________________________________________________________
(Name of Insurer)
(the "Insurer"), of_________________________________________________________ ______________
(Address of Insurer)
hereby certifies that it has issued liability insurance covering bodily injury and property damage including
environmental restoration for sudden accidental occurrences to
_____________________________________________________________________________________
(Name of Insured)
(the "Insured"), of ______________________________________________________________________
(Physical Address of Insured)
in connection with the insured's obligation to demonstrate financial responsibility under Florida
Administrative Code Rule 62-710.600(2) and 62-730.170. The coverage applies at:
EPA/DEP I.D. No.
Name
Physical Address
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
(If coverage is for multiple facilities, identify each facility insured.)
This insurance is primary and the company shall not be liable for amounts in excess of
$___________________for each accident, exclusive of legal defense costs. The coverage is provided
under policy number ________________, issued on ___________________.
(date)
The effective date of said policy is_____________________ and the expiration date of said policy
(date)
is____________________________.
(date)
This insurance is excess and the company shall not be liable for amounts in excess of
$_____________________for each accident in excess of the underlying limit of
$_____________________for each accident, exclusive of legal defense costs. The coverage is provided
under policy number____________________, issued on____________________. The effective date of
(date)
said policy is ___________________and the expiration date of said policy is ______________________.
(date)
(date)
Page 1 of 2
DEP FORM 62-730.900(5)(a), incorporated in Rule 62-730.170(2)(b), and 62-710.600(2)(e), F.A.C., Effective Date 4-23-13

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