Certification of Financial Responsibility




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Certification of Financial Responsibility
[Owner or operator name] hereby certifies that it is in compli­ance with the requirements of 329 IAC 9-8.
The financial assurance mechanism(s) used to demonstrate financial responsibility under 329 IAC 9-8 is (are) as follows:
Original text from 329 IAC 9-8-21(c): [For each mechanism, list the type of mechanism, name of issuer, mechanism number (if applicable), amount of coverage, effective period of coverage, and whether the mechanism covers "taking corrective action" or "compensating third parties for bodily injury and property damage caused by" or "taking correc­tive action and compensating third parties for bodily injury and property damage caused by" either "sudden accidental releases" or "nonsudden accidental releases" or "accidental releases".]
What it could look like: [Type of mechanism] in the amount of $XX,000 to cover the deductible for coverage under Indiana’s Excess Liability Trust Fund due to [Owner or operator name] owning or operating 12 or fewer [or 13 or more] petroleum underground storage tanks. The [Type of mechanism] is for the period of [date range]. This mechanism covers the deductible required by the Excess Liability Trust Fund in the amount of $2,000,000 per occurrence for taking corrective action and/or compensating third parties for bodily injury and property damage caused by either sudden accidental releases and/or nonsudden accidental releases.


[Signature of owner or operator]

[Name of owner or operator]

[Title]


[Date]


[Signature of witness or notary]

[Name of witness or notary]

[Date]


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