Form Dpr Pml 052 PDF Details

In the realm of pest control in California, ensuring that businesses are properly insured is crucial for both the protection of the public and the environment. The DPR-PML-052 form, issued by the State of California's Department of Pesticide Regulation within the Pest Management and Licensing Branch, serves as a Certificate of Insurance for pest control businesses seeking licensure. Located at 1001 I Street, Sacramento, this form certifies to the Director of the Department of Pesticide Regulation that a business, identified by name, has secured insurance coverage from a specified insurer. This documentation outlines the limits of coverage across various categories including bodily injury, property damage, and chemical liability, each with specified limits per person, per occurrence, and an annual aggregate. Moreover, the form accommodates the inclusion of details concerning covered aircraft, indicating a thorough approach to all aspects of pest control operations, from ground activities to aerial applications. Additionally, it captures essential information about the insured business and the insurance provider, including contact details which might facilitate further communication. The form also underscores a commitment to regulatory compliance and consumer protection, mandating that the insurance company pledges to notify the Department of any policy changes, underscoring the form's role in fostering transparency and accountability within the industry.

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Form NameForm Dpr Pml 052
Form Length1 pages
Fillable?No
Fillable fields0
Avg. time to fill out15 sec
Other namespr pml 052 california department of pesticide dpr pml 052 form

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STATE OF CALIFORNIA

PEST MANAGEMENT AND LICENSING BRANCH

DEPARTMENT OF PESTICIDE REGULATION

1001 I STREET

CERTIFICATE OF INSURANCE

SACRAMENTO, CA 95814-2828

P.O. BOX 4015

DPR-PML-052 (REV. 08/11)

SACRAMENTO, CA 95812-4015

 

 

(916) 445-4038

 

FAX (916) 445-4033

 

Web site: http://www.cdpr.ca.gov

This is to certify to the Director of the Department of Pesticide Regulation, whose address is 1001 I Street, Sacramento, California

95814-2828 that (name of business), an applicant for a pest control business license, is at this date insured with

(Insurance Company) for the Limits of Coverage stated below.

Coverage Descriptive Schedule

Insurance Coverage

Policy

Expiration

Limit of Liability

Limit of Liability

 

Limit of Liability

Number(s)

Date(s)

 

 

Per Person

Per Occurrence

Annual Aggregate

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

1.

Bodily injury including Chemical

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Liability

 

 

$

 

$

 

 

$

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

2.

Property Damage including

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Chemical Liability

 

 

$

 

 

$

 

 

$

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

3.

Combined Single Limit for Bodily

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Injury and Property Damage

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

including Chemical Liability

 

 

 

 

 

$

 

 

$

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

List of Covered Aircraft (Attach additional sheet if necessary)

Aircraft "N" Number

Aircraft Usages (Chemical Use/Nonchemical Use)

Remarks

1) N

 

 

2) N

 

 

3) N

 

 

Insured Information

INSURED BUSINESS NAME

 

PEST CONTROL BUSINESS LICENSE NUMBER (Optional)

BUSINESS LOCATION ADDRESS

CITY

STATE

ZIP CODE

Insurance Company and Insurance Agent/Broker Information

1. INSURANCE COMPANY NAME

FAX NUMBER (Optional)

EMAIL ADDRESS (Optional)

PHONE NUMBER (Optional)

 

(

 

 

)

MAILING ADDRESS

CITY

 

STATE

ZIP CODE

CONTACT PERSON NAME (Optional)

2. INSURANCE AGENT/BROKER NAME (Optional)

FAX NUMBER (Optional)

EMAIL ADDRESS (Optional)

PHONE NUMBER (Optional)

 

(

 

)

 

MAILING ADDRESS (Optional)

CITY (Optional)

 

STATE (Optional)

ZIP CODE (Optional)

CONTACT PERSON NAME (Optional)

The undersigned hereby certifies that liability insurance issued to the aforementioned insured, fulfills the requirements stated above and the requirements pursuant to Section 6524, of Title 3, of the California Code of Regulations.

The issuing company agrees that in the event of non-renewal or material change, including cancellation or reduction of coverage of the policy(ies), the issuing company will endeavor to give the party to whom the Certification is issued 30 days advance notice of such non-renewal or change, but the issuing company shall not be liable in any way for failure to give such notice.

INSURANCE REPRESENTATIVE SIGNATURE

DATE

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2. Immediately after this selection of blanks is completed, proceed to enter the applicable information in these - List of Covered Aircraft Attach, Aircraft Usages Chemical, Remarks, Insured Information, INSURED BUSINESS NAME, PEST CONTROL BUSINESS LICENSE, BUSINESS LOCATION ADDRESS, CITY, STATE, ZIP CODE, Insurance Company and Insurance, FAX NUMBER Optional, EMAIL ADDRESS Optional, MAILING ADDRESS, and CONTACT PERSON NAME Optional.

Filling in section 2 of Form Dpr Pml 052

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