ENDORSEMENT
Name: ___________________________________________ [name of each covered location]
Address: _________________________________________ [address of each covered location]
______________________________________________________________________
______________________________________________________________________
Policy Number: ________________________________________________________________
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]: _____________________________________________________________________________
______________________________________________________________________________
Endorsement:
List for each Facility: the name and address of the Facility where ASTs assured by this Policy Endorsement are located, and indicate which ASTs are assured by this Policy Endorsement. List each AST by the AST identification number provided in the registration form submitted pursuant to Part A of this regulation.
AST Facility I.D. Number: ____________________ (as listed on DNREC registration certificate)
Facility Name: ______________________________________________________________
Facility Street: ______________________________________________________________
Facility City: _____________________________________ Facility Zip Code: ____________
For [insert: "taking Corrective Action" and/or "compensating third parties for Bodily Injury and Property Damage caused by"] Accidental Releases in accordance with and subject to the limits of liability, exclusions, conditions, and other terms of the policy; [if coverage is different for different ASTs or locations, indicate the type of coverage applicable to each ASTs or location] arising from operating the AST(s) identified above.
The limits of liability are [insert the dollar amount of the "each Occurrence" and "Annual Aggregate" limits of the Insurer's or Group's liability; if the amount of coverage is different for different types of coverage or for different ASTs or locations, indicate the amount of coverage for each type of coverage and/or for each AST or location], exclusive of Legal Defense Costs which are subject to a separate limit under the policy. This coverage is provided under _______________. The Effective Date of said policy is _______________. [Policy Number] [Date]
The insurance covers claims otherwise covered by the policy that are reported to the ["Insurer" or "Group"] within six (6) months of the Effective Date of the 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, PART D, Section 23.0 Form C, of the Delaware Regulations Governing Aboveground Storage Tanks as constituted on the date shown immediately below and that the ["Insurer" or "Group"] is ["licensed to transact the business of insurance or eligible to provide insurance as an excess or surplus lines insurer in one or more States"].
Signature of authorized representative of [Insurer or Risk Retention Group]:
_________________________________________________________________________
Name of Person signing: ______________________________________________________
Print legibly or type
Title of Person signing: ______________________________________________________
Print legibly or type
Authorized Representative of [name of Insurer or Risk Retention Group]
Address of Representative: _____________________________________________________
Print legibly or type
7 Del. Admin. Code § 1352-D-23.0
27 DE Reg. 536 (1/1/2024) (Final)