35 Ill. Adm. Code 807.APPENDIX A
A Financial Assurance Forms
Section 807.APPENDIX AÂ Â
Financial Assurance Forms
Section 807.ILLUSTRATION FÂ Â Certificate
of Insurance for Closure and/or Post-Closure Care
CERTIFICATE
OF INSURANCE FOR CLOSURE AND/OR POST-CLOSURE CARE
Name and Address of Insurer ("Insurer"):
Name and Address of Insured
("Insured"):
Sites Covered:
Name
Address
City
Amount insured
for this site:
$
Name
Address
City
Amount insured
for this site:
$
Please attach a separate page
if more space is needed for all sites.
Face Amount:
Policy Number:
Effective
Date:
The Insurer hereby certifies
that it is licensed to transact the business of insurance by the Illinois
Department of Insurance or that it is licensed to transact the business of
insurance, or approved to provide insurance as an excess or surplus lines
insurer, by the insurance department in one or more states.
The insurer hereby certifies
that it has issued to the Insured the policy of insurance identified above to
provide financial assurance for closure and post-closure care for the sites
identified above. The Insurer further warrants that such policy conforms in
all respects with the requirements of 35 Ill. Adm. Code 807.665, as applicable
and as such regulations were constituted on the date shown immediately below.Â
It is agreed that any provision of the policy inconsistent with such
regulations is hereby amended to eliminate such inconsistency.
Whenever requested by the
Illinois Environmental Protection Agency ("IEPA"), the Insurer agrees
to furnish to the IEPA a duplicate original of the policy listed above,
including all endorsements thereon.
I hereby certify that the
wording of this certificate is identical to the wording specified in 35 Ill.
Adm. Code 807.Appendix A, Illustration F as such regulations were constituted
on the date shown below.
Name (Authorized signature for
Insurer)
Typed Name
Title
Date