Financial Assurance for Hazardous Waste Facilities - Certificate of Insurance
This information is provided by the Nebraska Department of Environment and Energy to assist the public and regulated community.
Form #: 05-174I Financial Assurance Revised: 8/16/22

40 CFR ยง 264.151 (e) A certificate of insurance, as specified in Sec. 264.143(e) or Sec. 264.145(e) or Sec. 265.143(d) or Sec. 265.145(d), must be worded as follows, except that instructions in brackets are to be replaced with the relevant information and the brackets deleted:

Certificate of Insurance for Closure or Post-Closure Care

Name and Address of Insurer
(herein called the ``Insurer''): _______________________________________________________

Name and Address of Insured
(herein called the ``Insured''): ______________________________________________________

Facilities Covered: [List for each facility: The NDEE Identification Number, name, address, and the amount of insurance for closure and/or the amount for post-closure care (these amounts for all facilities covered must total the face amount shown below).]

Face Amount: _____________________________________________________________________

Policy Number: ____________________________________________________________________

Effective Date: _____________________________________________________________________

The Insurer hereby certifies that it has issued to the Insured the policy of insurance identified above to provide financial assurance for [insert ``closure'' or ``closure and post- closure care'' or ``post-closure care''] for the facilities identified above. The Insurer further warrants that such policy conforms in all respects with the requirements of 40 CFR 264.143(e), 264.145(e), 265.143(d), and 265.145(d), as applicable and as such regulations were constituted on the date shown immediately below. It is agreed that any provision of the policy inconsistent with such regulations is hereby amended to eliminate such inconsistency.

Whenever requested by the Director of the Nebraska Department of Environment and Energy (NDEE), the Insurer agrees to furnish to the NDEE Director a duplicate original of the policy listed above, including all endorsements thereon.

I hereby certify that the wording of this certificate is identical to the wording specified in 40 CFR 264.151(e) as such regulations were constituted on the date shown immediately below.

[Authorized signature for Insurer] ______________________________________________________

[Name of person signing] ______________________________________________________________

[Title of person signing] _______________________________________________________________

Signature of witness or notary: _________________________________________________________

[Date] ___________________

Produced by:

Nebraska Department of Environment and Energy
P.O. Box 98922
Lincoln, NE 68509-8922

phone (402) 471-2186

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