Agr Form 702 4279 – Fill Out and Use This PDF

Important: This FRIC is for Commercial Applicators who apply pesticides. There are separate forms used to verify coverage for individuals

who perform wood destroying organism (WDO) inspections. A Commercial Applicator who applies pesticides and conducts complete WDO inspections must meet the inancial coverage requirements of both the Commercial Applicator and the Structural Pest Inspector license.

Complete WDO inspections are done for the purpose of determining evidence of infestation, damage, or conducive conditions as part of the transfer, exchange, or reinancing of any structure. For further information on the inancial coverage requirements and options for

both licenses, go to http://agr.wa.gov/PestFert/LicensingEd/CaSpiInfo.aspx.

WSDA accepts faxes, e-mails and copies of this completed form.

Instructions: This form is only valid when completed by the Commercial Applicator's Insurance Agent. For new licenses, this form must be submitted BEFORE the Commercial Applicator license can be issued. For existing licenses, it must be submitted by the expiration date of the Commercial Applicator's insurance policy or that license is automatically suspended.

Washington pesticide law (Chapter 17.21 RCW) requires that all Commercial Applicators submit proof of inancial responsibility. Com- mercial Pesticide Applicators must have a surety bond or liability insurance policy that covers the pesticide applications of the business in the amount of at least $50,000 per occurrence for bodily injury and $50,000 per occurrence for property damage including loss of damage arising out of the actual use of any pesticide not excluded below, including chemical drift damage onto property other than the property to which the chemical is being applied. The maximum deductible is $5,000. Use this form if reporting a liability insurance policy; there is a separate form for reporting a surety bond.

The following described Insurance Policy has been issued and is in full force and effect as set forth below:

EXCLUSIONS: FRIC not valid unless one of the following is checked:

No pesticides are excluded from this policy.

The following pesticides are excluded: __________________________________________________________

Only the following pesticides are covered: _______________________________________________________

List all aerial equipment covered by this Policy:
Aircraft Number: N-________________________	N- _______________________	N-_______________________
N-________________________	N- _______________________	N-_______________________

Agent Declaration

I certify that I have legal authority to act for _____________________________________________________ ; that said company is

PLACE OF EMPLOYMENT

a direct representative of the Underwriters and that said company is qualiied to do business in the state of Washington; and that the

insurance coverage is placed through a properly licensed agent in Washington.

It is agreed that the company will ile with the Department of Agriculture WITHIN TEN DAYS copies of any and all endorsements extend- ing, restricting, changing, cancelling or renewing the aforementioned coverage. Whenever requested by the Department, the company

agrees to furnish a copy of said policy and all endorsements thereon.

Authorized Agent (please print): _______________________________________________________________________________

Signature: __________________________________________________________

Date: ____________________________

NOTE: Fax, e-mail or mail the completed form to the Department of Agriculture (addresses above).

AGR FORM 702-4279 (R/11/12)