HomeMy Public PortalAboutDeclarations Page Policy #1430PSTF Form #5
Rev. 7/09
IDAHO PETROLEUM CLEAN WATER TRUST FUND
DECLARATIONS PAGE
Policy No. 1430
Petroleum Storage Tank Fund
P.O. Box 83720
Boise, ID 83720-0044
(208) 332-8100
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J U L 1 8 2012
This Policy consists of the declarations page, attached schedule of covered petroleum storage
tanks, the original policy contract (PSTF Form No. 4), any attached endorsements, and any
other attached provisions or materials. This policy is made and accepted subject to the terms
and conditions contained in this declarations page, the policy contract, and any attached
endorsements, schedules, or other materials. This declarations page must be dated and signed
by the Manager of the State Insurance Fund (SIF) which is the administrator of the Idaho
Petroleum Clean Water Trust Fund (IPCWTF) which does business as the Petroleum Storage
Tank Fund (PSTF) under a facsimile signature and countersigned and dated by an authorized
representative of the PSTF before any coverage is assumed by the IPCWTF under this policy.
NAMED INSURED: City of McCall - Golf Course
TAX IDENTIFICATION NO.: * * * * * * * *
MAILING ADDRESS: 216 East Park Street
Mccall, ID 83638
FORM OF BUSINESS: City or Municipality
POLICY PERIOD: From 08/01/2012 To 08/01/2013
12:01 a.m. at the Address of the Named Insured Stated Above
ENDORSEMENTS ATTACHED TO THIS POLICY AT TIME OF ISSUE:
N/A
DESCRIPTION AND LOCATION OF COVERED PETROLEUM STORAGE TANKS:
See attached Schedule A for each site of Covered Petroleum Storage Tanks.
LIMITS OF INSURANCE:
Non -Marketer <10,000 [Accidental release limit - $500,000.00; Aggregate limit -
$1,000,000.00]
StataInsurance Fund
State Insurance Fund as Administrator
Administrator, IPCW Trust Fund
August 01, 2012
Authorized PSTF Representative Date
Schedule A
Policy No. 1430
SITE IDENTIFICATION NO.:
LEGAL NAME OF OWNER/OPERATOR:
BUSINESS OR TRADE NAME OF SITE:
MAILING ADDRESS OF SITE:
430049
City of McCall - Golf Course
City of McCall - Golf Course
924 Fairway Drive
Mccall, ID 83638
Description of Covered Petroleum Storage Tanks
Tank Tank Type Capacity Petroleum Product Coverage
No. Stored Start Date
01 Underground 500
02 Underground 500
None
None
Site 11111111111111111111111111111111111
08/01/2012
08/01 /2012
PSTF Form #35
Rev. 7/09
Coverage
End Date
07/31 /2013
07/31 /2013
Date 7/17/2012
PSTF Form 022
Rev. 7/09
THIS ENDORSEMENT CHANGES THE INSURANCE CONTRACT TO WHICH IT IS ATTACHED.
PLEASE READ IT CAREFULLY.
This endorsement is attached to and forms a part of Policy No. 1430
Change Endorsement
MODIFICATION OF SITE(S) FROM ORIGINAL POLICY
NAMED INSURED: City of McCall - Golf Course
This endorsement modifies insurance provided by updating the below referenced site from the
original policy after the effective date of this policy.
SITE IDENTIFICATION NO.: 430049
LEGAL NAME OF OWNER/OPERATOR: City of McCall - Golf Course
BUSINESS OR TRADE NAME OF SITE: City of McCall - Golf Course
ADDRESS OF SITE: 924 Fairway Drive
Mccall, ID 83638
REASON FOR THIS ENDORSEMENT: Tank system is temporarily closed. Contents
have been changed to 'none'.
Petroleum
Tank Tank Type Capacity Product Stored
No.
01 Underground 500 None
02 Underground 500 None
If we issue this endorsement after the date your policy takes effect, we must complete these
spaces and our representative must sign below.
May 30, 2012
Authorized PSTF Representative Endorsement Effective Date