Fillable PROOF OF FINANCIAL SECURITY (Arizona Department of Agriculture)

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PROOF OF FINANCIAL SECURITY (Arizona Department of Agriculture)

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U.S.A. forms for Arizona Department of Agriculture

BROWSE ARIZONA DEPARTMENT OF AGRICULTURE (AZ) FORMS
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1688 W. Adams Street, Phoenix, Arizona 85007
E: licensing@azda.gov l P: 602.542.3578 l F: 602-542-0466
Douglas A. Ducey l Governor
Mark W. Killian l Director
PROOF OF FINANCIAL SECURITY
Proof of Financial Security must be submitted
before expiration date or the license is
automatically suspended. Form must be legible
and signed. Electronic signatures are acceptable.
Do not send multiple copies of the proof of
financial security unless requested by PMD staff.
INSURED
Business License Name (as licensed by the Department):
PMD License No.
Address:
Phone: Fax / Email (optional):
INSURER
Name:
Address:
Phone: Fax / Email (optional):
PRODUCER/BROKER
Name:
Address:
Phone: Fax / Email (optional):
Policy Number
Eff. Date
(mm/dd/yy)
Exp. Date
(mm/dd/yy)
P O L I C Y L I M I T S
Each Occurrence
($500K minimum)
$
General Aggregate
($500K minimum)
$
General Liability - Current law requires not less than $500K for operations from
insured’s primary office and any branch office.
Termite Damage due to
Negligent Treatment
($100K minimum if applicable)
$
Notice of policy changes - Should the policy be cancelled, revoked or fall
below the minimum limits, or if the deductible is increased to greater than 1% of
the total financial responsibility, the insurer will mail written notice to the Arizona
Pest Management Division within thirty (30) days.
WDIIR**
($100K minimum if applicable)
$
Deductible
Do not leave blank –
$0 minimum
$
business licensee provide Termite Treatments? ☐ Yes ☐ No
Inspection Category(s), does this business licensee provide Wood-Destroying Insect Inspection Reports? ☐ Yes ☐ No
Revised Statutes § 3-3615. If financial responsibility is insurance, the insured shall maintain a coverage endorsement for pesticides and
herbicides, fumigation, care custody and control, rights-of-way, wood-destroying insect inspection report errors and omissions, wood-
destroying organism management, and pollution transit for its applicable license categories.
Please check each of the license categories below covered by this policy:
☐
Industrial & Institutional (1)
☐
Ornamental & Turf (3)
☐
Fumigation (6)
☐
Wood-Destroying Organism Treatment & Inspection (2A)
☐
Right-of-Way (4)
☐
Wood Preservation (7)
☐
Wood-Destroying Insect Inspection (2B)
☐
Aquatic (5)
I certify that I am a duly authorized representative of the insurance company and the company holds a valid certificate of authority or is
permitted to transact surplus lines insurance in Arizona. When requested, the company agrees to furnish the PMD a complete copy of
the policy, including endorsements.
____________________________________________________ ___________________
Authorized Agent Name/Title (Please Print) Date
_____________________________________________________ Check one: Filled out by Producer/Broker ☐
☐
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1688 W. Adams Street, Phoenix, Arizona 85007
E: licensing@azda.gov l P: 602.542.3578 l F: 602-542-0466
Douglas A. Ducey l Governor
Mark W. Killian l Director
P
roof of Financial Security
Please Reference Arizona Revised Statute 3-3615 for specific details.
The Arizona Department of Agriculture (AZDA) - Pest Management Division (PMD) will only accept the
Proof of Financial Security document located on the AZDA website (https://agriculture.az.gov/download-forms).
No other Certificates of Insurance will be accepted (i.e. Acord Certificate of Liability Insurance form).
A Business Licensee is required to provide proof of financial security in an amount no less than
$500,000.00 at all times during the licensing period.
General Aggregate – this is the maximum the insurance company will pay out.
The Proof of Financial Security must provide the deductible amount of the policy: If an insurance
policy provides for a deductible, the deductible amount shall not exceed one per cent of the total financial
security for each occurrence. If the deductible amount is in excess of one per cent of the total financial
security for each occurrence, the business licensee shall provide other security as provided in this subsection
or other evidence of financial security for the excess deductible amount.
Example: If your General Aggregate is $2,500,000.00; your deductible cannot exceed $25,000.00
If certified in the Wood-Destroying Organism Treatment & Inspection Category: the Business Licensee is
required to have an endorsement with a minimum of $100,000.00 pursuant to A.R.S. § 3-3615 (3)(b) for
Termite Damage due to Negligent Treatment.
If certified in the Wood-Destroying Organism Treatment & Inspection or Wood-Destroying Insect
Inspection Category, and performs Wood-Destroying Insect Inspection Reports (WDIIR): the Business
Licensee is required to have an endorsement with a minimum of $100,000.00 for errors and omissions (E & O)
contained in the reports pursuant to A.R.S. § 3-3615 (3)(c). Business Licensees that do not provide Wood-
Destroying Insect Inspection Reports are not required to have this endorsement.
If financial security is in the form of liability insurance, a licensee shall maintain a coverage endorsement
for pesticides and herbicides, fumigation, care, custody and control, rights-of-way, wood-destroying insect
inspection report errors and omissions, and pollution transit for its applicable license categories.
(1) Industrial and Institutional: pest management in or about a residential or other structure excluding anti-
microbial pest management, fungi inspection, or pest management covered by another certification category.
This includes public health pest management such as adult mosquitoes.
(2A) Wood-destroying organism inspection & treatment: inspecting for the presence or absence of wood-
destroying organisms and treating for wood-destroying organisms in or about a residential or other structure by
a means other than use of a fumigant.
(2B) Wood-destroying insect inspection: inspecting for the presence or absence of wood-destroying insects
only and excluding preparing treatment proposals.
(3) Ornamental & Turf: pest management, including weeds, in the maintenance of ornamental trees, shrubs,
flowers, and turf by a means other than use of a fumigant.
(4) Right-of-Way: pest management, including weeds, in the maintenance of public roads, electric powerlines,
pipelines, railway rights-of-way or other similar areas by means other than use of a fumigant.
(5) Aquatic: pest management, including weeds and mosquito larvae, in standing or running water.
(6) Fumigation: pest management using fumigants.
(7) Wood preservation: application of pesticides directly to structural components of wood or wood products,
which are not part of an existing structure normally habitable by persons, to prevent or manage wood
degradation by wood-destroying organisms including fungi and bacteria.
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Completed 15 April 2021

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