State Form 23447 (R6 / 9-15)
One North Capitol Avenue, Suite 600
Indianapolis, Indiana 46204
Telephone: (317) 232-1360
Fax: (317) 232-1362
File number
Issued by (name of insurance company):
Address (number and street, city, state, and ZIP code)
THIS IS TO CERTIFY THAT there is now in effect an insurance policy(ies) issued by this company, policy number(s) as listed below, insuring all grain
contained, in the name of the indicated business firm against loss by fire, internal explosion, lightning, and windstorm pursuant to IC 26-3-7-12,
824 IAC 2-4-6.
Name of insured business firm Monthly reporting required?
Yes No
Address of headquarters (number and street, city, state, and ZIP code)
E-mail address May be send official communications via e-mail?
Yes No
Policy Number
Effective Policy Date
(month, day, year)
Name and Location of Insured Facility
Expiration Policy Date
(month, day, year)
Limit of Liability
for Grain
This certificate is furnished as a matter of information only and covers no rights upon the holder. It is issued with the understanding that the rights and
limitations of the parties will be governed by the original policy as it may be lawfully amended by endorsement from time to time. Insurance is afforded
only with respect to such and so many of the above policies and coverages thereunder as are stated therein, subject to all terms of the policy having
reference thereto.
This further certifies that, pursuant to Ind. Code § 26-3-7-14, the insurer will not cancel or reduce the limit of liability of the above listed policy(ies) except
after the expiration of a thirty (30) day period from the mailing, by certified mail, of notice of intent to cancel, to the Director of the Indiana Grain Buyers
and Warehouse Licensing Agency. A copy of such notice will be mailed to the entity referenced on the policy and licensed under IC 26-3-7, et seq., at
the time of giving notice to the Director. The cancellation or reduction in the limit of liability shall not affect the liability accrued or which may accrue
under such insurance policy before the expiration of the thirty-day period.
It is understood that the licensed entity that is insured may not cancel or reduce the limits of the policy(ies) listed above without the prior written approval
of the Director of the Indiana Grain Buyers and Warehouse Licensing Agency, and the Director’s receipt and approval of a substitute cash deposit or
approval of a substitute bond or insurance.
CERTIFICATE HOLDER: Director, Indiana Grain Buyers & Warehouse Licensing Agency
Signature of licensed agent Date of issue of certificate (month, day, year)
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