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

40 CFR ยง 264.151 (j) A certificate of liability insurance as required in Sec. 264.147 or Sec.
must be worded as follows, except that the instructions in brackets are to be replaced with the relevant information and the brackets deleted:

Hazardous Waste Facility Certificate of Liability Insurance

1. [Name of Insurer], (the "Insurer''), of [address of Insurer] hereby certifies that it has issued liability insurance covering bodily injury and property damage to [name of insured], (the "insured''), of [address of insured] in connection with the insured's obligation to demonstrate financial responsibility under 40 CFR 264.147 or 265.147. The coverage applies at [list NDEE Identification Number, name, and address for each facility] for [insert "sudden accidental occurrences,'' "nonsudden accidental occurrences,'' or "sudden and nonsudden accidental occurrences''; if coverage is for multiple facilities and the coverage is different for different facilities, indicate which facilities are insured for sudden accidental occurrences, which are insured for nonsudden accidental occurrences, and which are insured for both]. The limits of liability are [insert the dollar amount of the "each occurrence'' and "annual aggregate'' limits of the Insurer's liability], exclusive of legal defense costs. The coverage is provided under policy number ------, issued on [date]. The effective date of said policy is [date].

2. The Insurer further certifies the following with respect to the insurance described in Paragraph 1:
(a) Bankruptcy or insolvency of the insured shall not relieve the Insurer of its obligations under the policy.

(b) The Insurer is liable for the payment of amounts within any deductible applicable to the policy, with a right of reimbursement by the insured for any such payment made by the Insurer. This provision does not apply with respect to that amount of any deductible for which 265.147(f).

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

(d) Cancellation of the insurance, whether by the insurer, the insured, a parent corporation providing insurance coverage for its subsidiary, or by a firm having an insurable interest in and obtaining liability insurance on behalf of the owner or operator of the hazardous waste management facility, will be effective only upon written notice and only after the expiration of 60 days after a copy of such written notice is received by the NDEE Director.

(e) Any other termination of the insurance will be effective only upon written notice and only after the expiration of thirty (30) days after a copy of such written notice is received by the NDEE Director.

I hereby certify that the wording of this instrument is identical to the wording specified in 40 CFR 264.151(j) as such regulation was constituted on the date first above written, and that the Insurer is licensed to transact the business of insurance, or eligible to provide insurance as an excess or surplus lines insurer, in one or more States.

[Signature of authorized representative of Insurer] _______________________________________________

[Type name] ___________________________________________________________________________________

[Title], Authorized Representative of [name of Insurer] ___________________________________________

[Address of Representative] ____________________________________________________________________


Produced by:

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

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