Insurance Coverage
Policy
Number(s)
Expiration
Date(s)
Limit of Liability
Per Person
Limit of Liability
Per Occurrence
Limit of Liability
Annual Aggregate
1. Bodily injury including Chemical
Liability
$
$ $
2. Property Damage including
Chemical Liability
$ $ $
3. Combined Single Limit for Bodily
Injury and Property Damage
including Chemical Liability
$
$
$
STATE OF CALI
FORNIA
DEPARTMENT OF PESTICIDE REGULATION
PEST MANAGEMENT AND LICENSING BRANCH
1001 I STREET
SACRAMENTO, CA 95814-2828
P.O. BOX 4015
SACRAMENTO, CA 95812-4015
(916) 445-4038
FAX (916) 445-4033
Web site: http://www.cdpr.ca.gov
CERTIFICATE OF INSURANCE
DPR-PML-052 (REV. 08/11)
This is to certify to the Director of the Department of Pesticide Regulation, whose address is 1001 I Street, Sacramento, California
95814-2828 that (name of business), an applicant for a
pest control business license, is at this date insured with
(Insurance Company) for the Limits of Coverage stated below.
Coverage Descriptive Schedule
List of Covered Aircraft (Attach additional sheet if necessary)
Aircraft "N" Number Aircraft Usages (Chemical Use/Nonchemical Use) Remarks
1) N
2) N
3) N
Insured Information
INSURED BUSINESS NAME
PEST CONTROL BUSINESS LICENSE NUMBER (Optional)
BUSINESS LOCATION ADDRESS
CITY
STATE
ZIP CODE
Insurance Company and Insurance Agent/Broker Information
1. INSURANCE COMPANY NAME
FAX NUMBER (Optional)
EMAIL ADDRESS
(Optional)
PHONE NUMBER (Optional)
MAILING ADDRESS
CITY
STATE
ZIP CODE
CONTACT PERSON NAME (Optional)
2. INSURANCE AGENT/BROKER NAME (Optional)
FAX NUMBER (Optional)
EMAIL ADDRESS
(Optional)
PHONE NUMBER (Optional)
MAILING ADDRESS (Optional)
CITY
(Optional)
STATE
(Optional) ZIP CODE (Optional)
CONTACT PERSON NAME (Optional)
The undersigned hereby certifies that liability insurance issued to the aforementioned insured, fulfills the requirements stated
above and the requirements pursuant to Section 6524, of Title 3, of the California Code of Regulations.
The issuing company agrees that in the event of non-renewal or material change, including cancellation or reduction of coverage
of the policy(ies), the issuing company will endeavor to give the party to whom the Certification is issued 30 days advance notice
of such non-renewal or change, but the issuing company shall not be liable in any way for failure to give such notice.
DATE
INSURANCE REPRESENTATIVE SIGNATURE
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signature
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