HAR §11-280.1-97. received by the insured

(Insert for claims-made policies: e. The insurance covers claims otherwise covered by the policy that are reported to the ("Insurer u or "Groupu] within six months of the effective date of cancellation or non-renewal of the policy except where the new or renewed policy has the same retroactive date or a retroactive date earlier than that of the prior policy, and which arise out of any covered occurrence that commenced after the policy retroactive date, if applicable, and prior to such policy renewal or termination date. Claims reported during such extended reporting period are subject to the terms, conditions, limits, including limits of liability, and exclusions of the policy.] I hereby certify that the wording of this instrument is identical to the wording in section 11-280 .1-97 (b) ( 1), Hawaii Administrative Rules, and that the ["Insureru or "Group"] is ["licensed to transact the business of insurance or eligible to provide insurance as an excess or surplus lines insurer in the State of Hawaii"]. [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] (2) CERTIFICATE OF INSURANCE Name: [name of each covered location] 280.1-120 3 5 8 4 §11-280.1-97 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: 1. [Name of Insurer or Risk Retention Group], [the "Insureru or "Group"], as identified above, hereby certifies that it has issued liability insurance covering the following underground storage tank(s): [List the number of tanks at each facility and the narne(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 section 3421-30, Hawaii Revised Statutes, or 40 C.F.R. section 280.22, or in the permit applications submitted under sections 11-280.1-324 and 11-280.1-326, Hawaii Administrative Rules, and the name and address of the facility.] for [insert: "taking corrective actionu and/or "compensating third parties for bodily injury and property damage caused byu either "sudden accidental releasesu or "nonsudden accidental releases" or "accidental releasesu; in accordance with and subject to the limits of liability, exclusions, conditions, and other terms of the policy; if coverage is different for different tanks or locations, indicate the type of coverage 280.1-121 §11-280.1-97 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 aggregaten 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, which are subject to a separate limit under the policy. This coverage is provided under [policy number]. The effective date of said policy is [date]. 2. The ["Insureru or "Group"] further certifies the following with respect to the insurance described in Paragraph 1: a. Bankruptcy or insolvency of the insured shall not relieve the ["Insurer" or "Group"] of its obligations under the policy to which this certificate applies. b. The ["Insureru or "Group"] is liable for the payment of amounts within any deductible applicable to the policy to the provider of corrective action or a damaged third-party, with a right of reimbursement by the insured for any such payment made by the ["Insurer" or "Group"]. This provision does not apply with respect to that amount of any deductible for which coverage is demonstrated under another mechanism or combination of mechanisms as specified in sections 11-280.1-95 to 11-280.1-102 and 11-280.1-104 to 11-280.1-107, Hawaii Administrative Rules. c. Whenever requested by the Hawaii director of health, the ["Insurer" or 280.1-122 3 5 8 4 §11-280.1-97 "Group"] agrees to furnish to the director a signed duplicate original of the policy and all endorsements. d. Cancellation or any other termination of the insurance by the ["Insurer" or "Group"], except for non-payment of premium or misrepresentation by the insured, will be effective only upon written notice and only after the expiration of sixty days after a copy of such written notice is received by the insured. Cancellation for non­ payment of premium or misrepresentation by the insured will be effective only upon written notice and only after expiration of a minimum of ten days after a copy of such written notice is received by the insured. [Insert for claims-made policies: e. The insurance covers claims otherwise covered by the policy that are reported to the ["Insurern or "Groupn ] within six months of the effective date of cancellation or non-renewal of the policy except where the new or renewed policy has the same retroactive date or a retroactive date earlier than that of the prior policy, and which arise out of any covered occurrence that commenced after the policy retroactive date, if applicable, and prior to such policy renewal or termination date. Claims reported during such extended reporting period are subject to the terms, conditions, limits, including limits of liability, and exclusions of the pol icy.] I hereby certify that the wording of this instrument is identical to the wording in section 11-280.1-97 (b) (2), Hawaii Administrative Rules, and that the 280.1-123 3 h ?-I '  I... §11-280.1-97 ["Insurer" or "Group"] is ["licensed to transact the business of insurance, or eligible to provide insurance as an excess or surplus lines insurer, in the State of Hawaii"]. [Signature of authorized representative of Insurer] (Type Name] [Title], Authorized Representative of [name of Insurer or Risk Retention Group] [Address of Representative] (c) Each insurance policy must be issued by an insurer or a risk retention group that, at a minimum, is licensed to transact the business of insurance or eligible to provide insurance as an excess or surplus lines insurer in the State of Hawaii. [Eff 7/15/18; comp 1/17/20; comp 7/8/21; comp MAR 212025 ] (Auth: HRS §§3421-3, 3421-36) (Imp: HRS §§342L-3, 342L-36)