A CERTIFICATE OF INSURANCE MUST BE SUBMITTED WITH THIS ...
OHIO DEPARTMENT OF AGRICULTURE Plant Health Division - Pesticide & Fertilizer Regulation Section 8995 East Main Street, Reynoldsburg, OH 43068-3399 Phone 614-728-6987 - Fax 614-728-4235 Email: [email protected] Web: www.agri.ohio.gov
License Period: October 1, 201 thru September 30, 201
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PART A – PESTICIDE BUSINESS LICENSE TYPES AND FEES (Check license type(s) you wish to obtain:) PESTICIDE APPLICATION BUSINESS LICENSE ($35.00) (MUST EMPLOY A COMMERCIAL APPLICATOR) ID# _______________ Applicators Name ____________________________
PESTICIDE SOLICITATION BUSINESS LICENSE ($35.00)
PESTICIDE REGISTERED LOCATION LICENSE (35.00) (Pesticide Application Business Number (Required) RESTRICTED USE PESTICIDE DEALER LICENSE ($35.00) PART B – BUSINESS INFORMATION
Email Address
Company Name: (See Page 2 for definition) Partnership Sole Proprietorship
Business Types
Corporation
Limited Liability Company (LLC)
Other
Type of Organizantion: (If other is marked above indicate the type of business) Owner/Operator: DBA/AKA: (If different than Company Name above)
A CERTIFICATE OF INSURANCE MUST BE SUBMITTED WITH THIS APPLICATION EXCEPT SOLICITATION AND DEALERS. PART C - ADDRESS AND SIGNATURE (Please Print) Actual Business Location (PO Box is not accepted) City Zip
Business Mailing Address State
County
City Zip
Phone
State County
Phone
Signature: _______________________________________________________ Date: ______________________________ PART D – PAYMENT METHOD Payment by check or money order payable to the Ohio Department of Agriculture must be mailed or hand delivered. No purchase orders are accepted. This application may be faxed provided it is a credit card payment ONLY. License payments are non refundable. Payment may be made with one check when submitting multiple applications. This application can be duplicated. This application and fee are only valid for the licensing period listed above. Number of licenses_______________________ X $35.00 each = Payment method: Check or Money Order # ____________________________
Discover
Visa
MasterCard
The following information is required before a credit card payment can be processed. Cardholder Name Credit Card Number Expiration Date
CVV (3 digits on back) (MM)
(YYYY)
Valid CC Signature _______________________________________
OHIO DEPARTMENT OF AGRICULTURE Page 2 PLANT HEALTH DIVISION - PESTICIDE & FERTILIZER REGULATION SECTION 8995 E MAIN STREET, REYNOLDSBURG, OH 43068-3399 PESTICIDE BUSINESS LICENSE: A pesticide business license is required for a business that applies pesticides to the property of another for hire, or solicits and takes orders to apply pesticides, or conducts diagnostic inspections for WDI in a contemplated real estate transaction. Considered as a Corporate or Parent Company. Proof of insurance is required for this license. COI REQUIRED PESTICIDE REGISTERED LOCATION LICENSE: Any additional location or branch operating in Ohio with the same name of a Pesticide Business that operates in Ohio. Must have a Pesticide Business License associated with it and the Certificate of Insurance must also list this location. COI REQUIRED PESTICIDE SOLICITATION BUSINESS LICENSE: A company that solicits only to obtain business. This license type is prohibited from making pesticide applications. A solicitation company contracts with a licensed pesticide business in Ohio to perform applications. DEALER: A person or facility who distributes Restricted Use Pesticides (RUP) or pesticides whose use are further restricted by the director to the ultimate user or to a commercial applicator who is employed by the pesticide dealer. A license is required for each location or outlet within the state from which the person distributes pesticides. Yearly reporting of sales is required. Reports of restricted use sales for the period July 1st to June 30th, and are due by July 31st of each year. DOING BUSINESS AS DBA: A DBA is a name that represents the business in place of the owners first and last name (if an individual), or the legal name of the business entity, where applicable (such as a corporation or LLC). It is also referred to as “fictitious business names, assumed business names and trade names”. All these terms mean the same thing. BUSINESS TYPES Sole Proprietorship: Is a business entity that is owned and run by one individual. There is no legal distinction between the owner and the business. Partnership: Is a business entity where owners, called partners, share both the risks and benefits of the business. This includes any profits or debts. Corporation: Is treated as a separate entity from the owners of the business. This type of business consists of a number of shareholders, each of whom has some say in the company’s actions. The more shares held by an individual, the more votes they have regarding company policies. In addition to being treated as a separate legal entity, corporations are often given the same rights as human beings in certain legal matters. Limited Liability Company (LLC): According to the US Internal Revenue Service, a limited liability company, similar to a corporation, allows owners to have limited personal liability for debts and actions of the company. The LLC also has features of the partnership structure, which provides management flexibility and the benefit of pass-through taxation. Owners of a LLC are often referred to as members. Most US states do not restrict this type of ownership.
INSURANCE REQUIREMENTS FOR PESTICIDE BUSINESS AND REGISTERED LOCATION LICENSES A Pesticide Business License will not be issued without a Certificate of Insurance. A comprehensive general liability insurance policy and either a separate professional liability policy or endorsement covering liability from the application of pesticides are required. The policy shall provide coverage for bodily injury, property damage, products & completed operations, and shall contain the following minimum limits of insurance: $300,000 general aggregate; $300,000 per occurrence limit; and $300,000 products and completed operations aggregate. The Certificate of Insurance must show the policy number, endorsements that insurance covers liability arising from the application of pesticides, name of agent. The company name and address must match exactly the name you list on your application. If your company uses a DBA this must be indicated on the Certificate of Insurance, - For Category 12 - WDI requirement: a specific liability policy or endorsement in the amount of $50,000 per occurrence with an aggregate limit of $100,000 covering claims which arise from errors or omissions in the performance of wood-destroying insect diagnostic inspections. The certificate must state professional liability for WDI or errors & omissions, not "pesticide endorsement" and not "including operations". COI REQUIRED WITH APPLICATION
Pesticide Business Insurance Requirements Applicants for a Pesticide Business License in Ohio must provide proof of financial responsibility before a license can be issued. This form may be mailed, faxed or emailed. Provisions of Ohio’s Administrative Code 901:5-11-06 specifying the insurance requirements are detailed below and include: (A) Every Pesticide Business issued a pesticide business license shall have in force, for the term of the license, a comprehensive general liability insurance policy and, either a separate professional liability insurance policy or an endorsement, covering liability arising from the application of pesticides in each of the specific user categories in which pesticide applicators employed by the business are licensed. The policy and endorsements shall be issued by a company authorized to do business in Ohio. The policy shall provide coverage for bodily injury, property damage, products and completed operations and shall contain the following minimum limits of insurance: (1) three hundred thousand dollars ($300,000) policy general aggregate; (2) three hundred thousand dollars ($300,000) per occurrence limit; and, (3) three hundred thousand dollars ($300,000) products and completed operations aggregate. The insurance policy shall also contain a clause which states in the same or similar language: "In the event of cancellation for nonpayment of premium the insurer agrees to advise the Ohio Department of Agriculture, Pesticide Regulation Section, 8995 East Main Street, Reynoldsburg, Ohio 43068, by written notice ten days prior to the effective date of cancellation. If the policy is, for any other reason, cancelled, not renewed, or there is a material change the insurer agrees to give the Ohio Department of Agriculture thirty days written notice." (B) Every Pesticide Business issued a pesticide business license which is also licensed in the category of wood-destroying insect diagnostic inspection shall obtain either a specific liability policy, or an endorsement on an existing comprehensive general liability policy, issued by a company authorized to do business in Ohio, in the amount of fifty thousand dollars per occurrence with an aggregate limit of at least one hundred thousand dollars covering claims which arise from errors or omissions in the performance of wood-destroying insect diagnostic inspections. (C) Every person applying for a pesticide business license shall submit with their license application either a certificate of insurance or a binder verifying that they meet the requirements of paragraph (A) of this rule; and, if they are licensed in the category of wood-destroying insect diagnostic inspection, verifying that they meet the requirements of paragraph (B) of this rule. The certificate of insurance or binder shall contain: (1) the name and address of the issuing company; (2) the name and address of the insured; (3) the effective date and expiration date of the insurance policy; (4) the policy number; (5) a statement verifying that the policy covers liability arising from the application of pesticides, and if applicable, liability arising from the performance of wood-destroying insect diagnostic inspections; and, (6) the limits of insurance. (D) Exclusions and Exemptions: the above requirements shall apply to all pesticide businesses, except pesticide businesses whose activities are limited to: (1) Application of boat antifoulants (2) Seed Treatment (3) Those performed as a pesticide solicitor Additionally, aerial pest control applicators shall have in force a minimum limit of insurance: one hundred thousand dollars $100,000) property damage per occurrence one hundred thousand dollars ($100,000) bodily injury coverage for each person three hundred thousand dollars ($300,000) bodily injury per occurrence
**** SAMPLE **** DATE (MM/DD/YYYY)
CERTIFICATE OF LIABILITY INSURANCE
REQUIRED (1) THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND, OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW
PRODUCER
Agents Name Address City, State & Zip Phone Number
Required (2)
INSURERS AFFORDING COVERAGE
NAIC #
INSURED
INSURER A:
Business Name Address City, State & Zip Phone Number
INSURER B:
Required (3)
INSURER C: INSURER D: INSURER E:
COVERAGES THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED, NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY E ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCIRBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES, AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR ADD'L LTR INSRD
TYPE OF INSURANCE GENERAL LIABILITY
X
POLICY NUMBER
COMMERCIAL GENERAL LIABILITY
X
CLAIMS MADE
Show Full Policy Number
POLICY EFFECTIVE DATE (MM/DD/YY)
Show Policy Term
POLICY EXPIRATION DATE (MM/DD/YY)
Show Policy Term
OCCUR
Required (4)
Required (5)
Required (6)
GEN'L AGGREGATE LIMIT APPLIES PER: PROJECT POLICY AUTOMOBILE LIABILITY
ALL OWNED AUTOS SCHEDULED AUTOS HIRED AUTOS NON-OWNED AUTOS
GARAGE LIABILITY
MED EXP Any one person)
$
PERSONAL & ADV INJURY
$
GENERAL AGGREGATE
$
PRODUCTS - COMP/OP AGG
$
COMBINED SINGLE LIMIT (Ea accident)
$
(7)
$
BODILY INJURY (Per person)
$
BODILY INJURY (Per accident)
$
PROPERTY DAMAGE (Per accident)
$
AUTO ONLY-EA ACCIDENT
ANY AUTO
Required (8) Required (9)
$
EA ACC
OTHER THAN AUTO ONLY :
EXCESS/UMBRELLA LIABILITY OCCUR
$ Required
LOC
ANY AUTO
X
LIMITS EACH OCCURANCE DAMAGE TO RENTED PREMISES (Ea occurrence)
AGG
EACH OCCURRENCE
CLAIMS MADE
$ $ $
AGGREGATE
$ $
DEDUCTIBLE RETENTION
$ $
$ WCSTATUTORYLIMITS
WORKERS COMPENSATION AND EMPLOYER'S LIABILITY ANY PROPRIETOR/PARTNER/EXECTUTIVE OFFICE/MEMBER EXCLUDED? If yes, describe under SPECIAL PROVISIONS below
OTHER $
E.L. EACH ACCIDENT
$
E.L. DISEASE - EA EMPLOYEE
$
E.LO. DISEASE - POLICY LIMIT
$
OTHER
DESCRIPTTION OF OPERATIONS / LOCATIONS / VEHICLES / EXCLUSIONS ADDED BY ENDORSEMENT / SPECIAL PROVISIONS
Required statement (10) Must state specifically “Policy covers liability arising from the application of Pesticides.” We can no longer accept the Ohio Pesticide Applicator endorsement. Required statement (11) if applicable CERTIFICATE HOLDER
CANCELLATION SHOULD ANY OF THE ABOVE DESCIRBED POLICIES BE CANCELLED BEFORE THE EXPIRATION
Ohio Department of Agriculture Pesticide Regulation Section 8995 East Main Street Reynoldsburg, Ohio 43068-3399
DATE THEREOF, THE ISSUING INSURER WILL ENDEAVER TO MAIL
AUTHORIZED REPRESENTATIVE
Required (13) **** SAMPLE ONLY***
Required 12
DAYS
WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO DO SO SHALL IMPOSE NO OBLIGATION OR LIABLITY OF ANY KIND UPON THE INSURER, ITS AGENTS OR REPRESENTATIVES.
OVER – REQUIRED FIELDS LISTED ON OTHER SIDE
License Period: October 1, 201 thru September 30, 201
PART A – PESTICIDE BUSINESS LICENSE TYPES AND FEES (Check license type(s) you wish to obtain:) PESTICIDE APPLICATION BUSINESS LICENSE ($35.00) (MUST EMPLOY A COMMERCIAL APPLICATOR) ID# _______________ Applicators Name ____________________________
PESTICIDE SOLICITATION BUSINESS LICENSE ($35.00)
PESTICIDE REGISTERED LOCATION LICENSE (35.00) (Pesticide Application Business Number (Required) RESTRICTED USE PESTICIDE DEALER LICENSE ($35.00) PART B – BUSINESS INFORMATION
Email Address
Company Name: (See Page 2 for definition) Partnership Sole Proprietorship
Business Types
Corporation
Limited Liability Company (LLC)
Other
Type of Organizantion: (If other is marked above indicate the type of business) Owner/Operator: DBA/AKA: (If different than Company Name above)
A CERTIFICATE OF INSURANCE MUST BE SUBMITTED WITH THIS APPLICATION EXCEPT SOLICITATION AND DEALERS. PART C - ADDRESS AND SIGNATURE (Please Print) Actual Business Location (PO Box is not accepted) City Zip
Business Mailing Address State
County
City Zip
Phone
State County
Phone
Signature: _______________________________________________________ Date: ______________________________ PART D – PAYMENT METHOD Payment by check or money order payable to the Ohio Department of Agriculture must be mailed or hand delivered. No purchase orders are accepted. This application may be faxed provided it is a credit card payment ONLY. License payments are non refundable. Payment may be made with one check when submitting multiple applications. This application can be duplicated. This application and fee are only valid for the licensing period listed above. Number of licenses_______________________ X $35.00 each = Payment method: Check or Money Order # ____________________________
Discover
Visa
MasterCard
The following information is required before a credit card payment can be processed. Cardholder Name Credit Card Number Expiration Date
CVV (3 digits on back) (MM)
(YYYY)
Valid CC Signature _______________________________________
OHIO DEPARTMENT OF AGRICULTURE Page 2 PLANT HEALTH DIVISION - PESTICIDE & FERTILIZER REGULATION SECTION 8995 E MAIN STREET, REYNOLDSBURG, OH 43068-3399 PESTICIDE BUSINESS LICENSE: A pesticide business license is required for a business that applies pesticides to the property of another for hire, or solicits and takes orders to apply pesticides, or conducts diagnostic inspections for WDI in a contemplated real estate transaction. Considered as a Corporate or Parent Company. Proof of insurance is required for this license. COI REQUIRED PESTICIDE REGISTERED LOCATION LICENSE: Any additional location or branch operating in Ohio with the same name of a Pesticide Business that operates in Ohio. Must have a Pesticide Business License associated with it and the Certificate of Insurance must also list this location. COI REQUIRED PESTICIDE SOLICITATION BUSINESS LICENSE: A company that solicits only to obtain business. This license type is prohibited from making pesticide applications. A solicitation company contracts with a licensed pesticide business in Ohio to perform applications. DEALER: A person or facility who distributes Restricted Use Pesticides (RUP) or pesticides whose use are further restricted by the director to the ultimate user or to a commercial applicator who is employed by the pesticide dealer. A license is required for each location or outlet within the state from which the person distributes pesticides. Yearly reporting of sales is required. Reports of restricted use sales for the period July 1st to June 30th, and are due by July 31st of each year. DOING BUSINESS AS DBA: A DBA is a name that represents the business in place of the owners first and last name (if an individual), or the legal name of the business entity, where applicable (such as a corporation or LLC). It is also referred to as “fictitious business names, assumed business names and trade names”. All these terms mean the same thing. BUSINESS TYPES Sole Proprietorship: Is a business entity that is owned and run by one individual. There is no legal distinction between the owner and the business. Partnership: Is a business entity where owners, called partners, share both the risks and benefits of the business. This includes any profits or debts. Corporation: Is treated as a separate entity from the owners of the business. This type of business consists of a number of shareholders, each of whom has some say in the company’s actions. The more shares held by an individual, the more votes they have regarding company policies. In addition to being treated as a separate legal entity, corporations are often given the same rights as human beings in certain legal matters. Limited Liability Company (LLC): According to the US Internal Revenue Service, a limited liability company, similar to a corporation, allows owners to have limited personal liability for debts and actions of the company. The LLC also has features of the partnership structure, which provides management flexibility and the benefit of pass-through taxation. Owners of a LLC are often referred to as members. Most US states do not restrict this type of ownership.
INSURANCE REQUIREMENTS FOR PESTICIDE BUSINESS AND REGISTERED LOCATION LICENSES A Pesticide Business License will not be issued without a Certificate of Insurance. A comprehensive general liability insurance policy and either a separate professional liability policy or endorsement covering liability from the application of pesticides are required. The policy shall provide coverage for bodily injury, property damage, products & completed operations, and shall contain the following minimum limits of insurance: $300,000 general aggregate; $300,000 per occurrence limit; and $300,000 products and completed operations aggregate. The Certificate of Insurance must show the policy number, endorsements that insurance covers liability arising from the application of pesticides, name of agent. The company name and address must match exactly the name you list on your application. If your company uses a DBA this must be indicated on the Certificate of Insurance, - For Category 12 - WDI requirement: a specific liability policy or endorsement in the amount of $50,000 per occurrence with an aggregate limit of $100,000 covering claims which arise from errors or omissions in the performance of wood-destroying insect diagnostic inspections. The certificate must state professional liability for WDI or errors & omissions, not "pesticide endorsement" and not "including operations". COI REQUIRED WITH APPLICATION
Pesticide Business Insurance Requirements Applicants for a Pesticide Business License in Ohio must provide proof of financial responsibility before a license can be issued. This form may be mailed, faxed or emailed. Provisions of Ohio’s Administrative Code 901:5-11-06 specifying the insurance requirements are detailed below and include: (A) Every Pesticide Business issued a pesticide business license shall have in force, for the term of the license, a comprehensive general liability insurance policy and, either a separate professional liability insurance policy or an endorsement, covering liability arising from the application of pesticides in each of the specific user categories in which pesticide applicators employed by the business are licensed. The policy and endorsements shall be issued by a company authorized to do business in Ohio. The policy shall provide coverage for bodily injury, property damage, products and completed operations and shall contain the following minimum limits of insurance: (1) three hundred thousand dollars ($300,000) policy general aggregate; (2) three hundred thousand dollars ($300,000) per occurrence limit; and, (3) three hundred thousand dollars ($300,000) products and completed operations aggregate. The insurance policy shall also contain a clause which states in the same or similar language: "In the event of cancellation for nonpayment of premium the insurer agrees to advise the Ohio Department of Agriculture, Pesticide Regulation Section, 8995 East Main Street, Reynoldsburg, Ohio 43068, by written notice ten days prior to the effective date of cancellation. If the policy is, for any other reason, cancelled, not renewed, or there is a material change the insurer agrees to give the Ohio Department of Agriculture thirty days written notice." (B) Every Pesticide Business issued a pesticide business license which is also licensed in the category of wood-destroying insect diagnostic inspection shall obtain either a specific liability policy, or an endorsement on an existing comprehensive general liability policy, issued by a company authorized to do business in Ohio, in the amount of fifty thousand dollars per occurrence with an aggregate limit of at least one hundred thousand dollars covering claims which arise from errors or omissions in the performance of wood-destroying insect diagnostic inspections. (C) Every person applying for a pesticide business license shall submit with their license application either a certificate of insurance or a binder verifying that they meet the requirements of paragraph (A) of this rule; and, if they are licensed in the category of wood-destroying insect diagnostic inspection, verifying that they meet the requirements of paragraph (B) of this rule. The certificate of insurance or binder shall contain: (1) the name and address of the issuing company; (2) the name and address of the insured; (3) the effective date and expiration date of the insurance policy; (4) the policy number; (5) a statement verifying that the policy covers liability arising from the application of pesticides, and if applicable, liability arising from the performance of wood-destroying insect diagnostic inspections; and, (6) the limits of insurance. (D) Exclusions and Exemptions: the above requirements shall apply to all pesticide businesses, except pesticide businesses whose activities are limited to: (1) Application of boat antifoulants (2) Seed Treatment (3) Those performed as a pesticide solicitor Additionally, aerial pest control applicators shall have in force a minimum limit of insurance: one hundred thousand dollars $100,000) property damage per occurrence one hundred thousand dollars ($100,000) bodily injury coverage for each person three hundred thousand dollars ($300,000) bodily injury per occurrence
**** SAMPLE **** DATE (MM/DD/YYYY)
CERTIFICATE OF LIABILITY INSURANCE
REQUIRED (1) THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND, OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW
PRODUCER
Agents Name Address City, State & Zip Phone Number
Required (2)
INSURERS AFFORDING COVERAGE
NAIC #
INSURED
INSURER A:
Business Name Address City, State & Zip Phone Number
INSURER B:
Required (3)
INSURER C: INSURER D: INSURER E:
COVERAGES THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED, NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY E ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCIRBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES, AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR ADD'L LTR INSRD
TYPE OF INSURANCE GENERAL LIABILITY
X
POLICY NUMBER
COMMERCIAL GENERAL LIABILITY
X
CLAIMS MADE
Show Full Policy Number
POLICY EFFECTIVE DATE (MM/DD/YY)
Show Policy Term
POLICY EXPIRATION DATE (MM/DD/YY)
Show Policy Term
OCCUR
Required (4)
Required (5)
Required (6)
GEN'L AGGREGATE LIMIT APPLIES PER: PROJECT POLICY AUTOMOBILE LIABILITY
ALL OWNED AUTOS SCHEDULED AUTOS HIRED AUTOS NON-OWNED AUTOS
GARAGE LIABILITY
MED EXP Any one person)
$
PERSONAL & ADV INJURY
$
GENERAL AGGREGATE
$
PRODUCTS - COMP/OP AGG
$
COMBINED SINGLE LIMIT (Ea accident)
$
(7)
$
BODILY INJURY (Per person)
$
BODILY INJURY (Per accident)
$
PROPERTY DAMAGE (Per accident)
$
AUTO ONLY-EA ACCIDENT
ANY AUTO
Required (8) Required (9)
$
EA ACC
OTHER THAN AUTO ONLY :
EXCESS/UMBRELLA LIABILITY OCCUR
$ Required
LOC
ANY AUTO
X
LIMITS EACH OCCURANCE DAMAGE TO RENTED PREMISES (Ea occurrence)
AGG
EACH OCCURRENCE
CLAIMS MADE
$ $ $
AGGREGATE
$ $
DEDUCTIBLE RETENTION
$ $
$ WCSTATUTORYLIMITS
WORKERS COMPENSATION AND EMPLOYER'S LIABILITY ANY PROPRIETOR/PARTNER/EXECTUTIVE OFFICE/MEMBER EXCLUDED? If yes, describe under SPECIAL PROVISIONS below
OTHER $
E.L. EACH ACCIDENT
$
E.L. DISEASE - EA EMPLOYEE
$
E.LO. DISEASE - POLICY LIMIT
$
OTHER
DESCRIPTTION OF OPERATIONS / LOCATIONS / VEHICLES / EXCLUSIONS ADDED BY ENDORSEMENT / SPECIAL PROVISIONS
Required statement (10) Must state specifically “Policy covers liability arising from the application of Pesticides.” We can no longer accept the Ohio Pesticide Applicator endorsement. Required statement (11) if applicable CERTIFICATE HOLDER
CANCELLATION SHOULD ANY OF THE ABOVE DESCIRBED POLICIES BE CANCELLED BEFORE THE EXPIRATION
Ohio Department of Agriculture Pesticide Regulation Section 8995 East Main Street Reynoldsburg, Ohio 43068-3399
DATE THEREOF, THE ISSUING INSURER WILL ENDEAVER TO MAIL
AUTHORIZED REPRESENTATIVE
Required (13) **** SAMPLE ONLY***
Required 12
DAYS
WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO DO SO SHALL IMPOSE NO OBLIGATION OR LIABLITY OF ANY KIND UPON THE INSURER, ITS AGENTS OR REPRESENTATIVES.
OVER – REQUIRED FIELDS LISTED ON OTHER SIDE
