EXAMPLE INSURANCE CERTIFICATION LETTER FORMAT
EXAMPLE INSURANCE CERTIFICATION LETTER FORMAT * DO NOT USE THIS PAGE. The EMR letter must be an originally signed letter from the Insurance Agent and on the Insurance Company’s letterhead stationery Date:_____ To: Virginia Department of Transportation 1401 East Broad Street Richmond, Virginia 23219
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CERTIFICATION OF FINANCIAL RESPONSIBILITY
www.waterboards.ca.govExample: insurance policy number, Letter of Credit number, etc., etc. If using the State Cleanup Fund, leave blank. Coverage Amount Indicate amount of coverage for each listed mechanism. If more than one mechanism is indicated, total must equal 100% of financial responsibility for each site.