Section 811.APPENDIX A   Financial Assurance Forms

Section 811.ILLUSTRATION F   Certificate of Insurance for Closure and/or Post-Closure Care or Corrective Action

CERTIFICATE OF INSURANCE FOR CLOSURE AND/OR

POST-CLOSURE CARE OR CORRECTIVE ACTION

Name and Address of Insurer ("Insurer"):________________________________________

Name and Address of Insured ("Insured"):________________________________________

Sites Covered:

Name__________________________________

Address__________________________________

City__________________________________

Amount insured for this site: $________________________

Name__________________________________

Address__________________________________

City__________________________________

Amount insured for this site: $________________________

Please attach a separate page if more space is needed for all sites.

Face Amount__________________________________

Policy Number__________________________________

Effective Date__________________________________

The Insurer hereby certifies that it is licensed to transact the business of insurance by the Illinois Department of Insurance or that it is licensed to transact the business of insurance, or approved to provide insurance as an excess or surplus lines insurer, by the insurance department in one or more states.

The insurer hereby certifies that it has issued to the Insured the policy of insurance identified above to provide financial assurance for [indicate: closure and/or post-closure care or corrective action] for the sites identified above.  The Insurer further warrants that such policy conforms in all respects with the requirements of 35 Ill. Adm. Code 811.714, 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 Illinois Environmental Protection Agency ("IEPA"), the Insurer agrees to furnish to the IEPA 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 35 Ill. Adm. Code 811.Appendix A, Illustration F as that regulation was constituted on the date shown below.

(Source:  Amended at 35 Ill. Reg. 10842, effective June 22, 2011)