Certificate of Insurance Form - Virginia

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***** CERTIFICATE OF INSURANCE *****
To the Virginia Department of Agriculture and Consumer Services:
I hereby certify that Policy # _______________________ provides coverage, in the
form of a general liability policy from a person authorized to do business in
Virginia or a certification thereof, protecting persons who may suffer legal
damages as a result of the use of any pesticide by the applicant. This policy is
in a minimum of:
$____________ for property damage, $____________ for personal injury and
$____________ per occurrence.
$____________ deductible amount (see reverse for deductible requirements)
Exclusions (please specify): ________________________________________________
This policy has been issued to:
(Name of Insured) (Address)
(Trading As, or D.B.A.) (Address)
Policy term:
Effective date: _____________ Expiration date: _____________
In the event of cancellation, the insurer agrees to advise the VDACS Office of
Pesticide Services, by written notice, at least 10 days prior to the effective
date of cancellation.
(Insurance Company Providing Coverage)
(Agency Issuing Policy) (Company Seal or Stamp)
(Street) (City) (State) (Zip)
_X
___________________________________________ ____________________________
(Signature - Authorized Representative) (Date of Certificate)
For acceptance by the Virginia Department of Agriculture and Consumer Services,
this form must be properly completed, validated and signed by the issuing
insurance agency. Mail completed certificate to the address below.
Certificate Holder:Office of Pesticide Services
Virginia Department of Agriculture and Consumer Services
P. O. Box 1163
Richmond, Virginia 23218
4-5-96 (see reverse side) VDACS-07214
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