YES
NO
ADDITIONAL INFORMATION
Provide a “one line” drawing of the main system components consisting of at least, but not
limited to the following:
1. Generation Source
2. Inverter
3. Utility AC Disconnect
4. Service Connection
Additional equipment such as batteries, DC disconnect, panel board, standby transfer switch,
etc. may also be included.
INSURANCE DISCLOSER
The Member, at Member's own expense, shall secure and maintain in
effect while
interconnected to the Warren County REMC's distribution system Comprehensive General
Liability Insurance and Contractual Liability Insurance insuring Member's indemnification
obligations and bodily injury, death and property damage with a combined single limit for
bodily injury and property damage of not less than $1,000,000.00 for each occurrence. A
Certificate of Insurance evidencing the requisite coverage shall be provided
to Warren
County REMC prior to interconnecting to Warren County REMC's distribution system and
annually upon renewal. Member shall be responsible for providing Warren County REMC
current and valid proof of current insurance coverage.
The Member will not be allowed to
commence or continue
interconnected operations
unless evidence is provided
that satisfactory
insurance coverage is in effect.
YES
IN PROCESS
MEMBER SIGNATURE
I hereby certify that:
1. I have read and understood the terms and conditions which are attached hereto.
2. I desire to interconnect my qualified distributed generation system to the distribution
system of Warren County REMC and take service under Rate Schedule DG
3. I hereby acknowledge and agree to the Terms & Conditions set forth in the Rate
Schedule DG, as may be amended from time to time by the Board of Directors.
4. To the best of my knowledge all of the information provided in this application form is
complete and true.
MEMBER SIGNATURE:
MEMBER NAME (PRINT):
DATE:
