Wisconsin Legislature: NR 661.0151 Text

Certificate of Insurance

Name and Address of Insurer (herein called the “Insurer”):

Name and Address of Insured (herein called the “Insured”):

Facilities Covered: [List for each facility: The EPA Identification Number (if any issued), name, address, and the amount of insurance for all facilities covered, which shall total the face amount shown below.]

Face Amount:

Policy Number:

Effective Date:

The Insurer hereby certifies that it has issued to the Insured the policy of insurance identified above to provide financial assurance so that in accordance with applicable regulations all hazardous secondary material can be removed from the facility or any unit at the facility and the facility or any unit at the facility can be decontaminated at the facilities identified above. The Insurer further warrants that such policy conforms in all respects with the requirements of s. NR 661.0143 (4), Wis. Adm. Code, 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 Wisconsin Department of Natural Resources, the Insurer agrees to furnish to the department 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 s. NR 661.0151 (4), Wis. Adm. Code, such regulations were constituted on the date shown immediately below.

[Authorized signature for Insurer]

[Name of person signing]

[Title of person signing]

Signature of witness or notary:

[Date]

NR 661.0151(5)(5) A letter from the chief financial officer, as specified in s. NR 661.0143 (5), shall be worded as follows, except that instructions in brackets are to be replaced with the relevant information and the brackets deleted:

Letter from Chief Financial Officer

[Address to Wisconsin Department of Natural Resources]

I am the chief financial officer of [name and address of firm]. This letter is in support of this firm’s use of the financial test to demonstrate financial assurance, as specified in subch. H of ch. NR 661, Wis. Adm. Code.

[Fill out the following nine paragraphs regarding facilities and associated cost estimates. If your firm has no facilities that belong in a particular paragraph, write “None” in the space indicated. For each facility, include its EPA Identification Number (if any issued), name, address, and current cost estimates.]

1. This firm is the owner or operator of the following facilities for which financial assurance is demonstrated through the financial test specified in subch. H of ch. NR 661, Wis. Adm. Code. The current cost estimates covered by the test are shown for each facility: ____.

2. This firm guarantees, through the guarantee specified in subch. H of ch. NR 661, Wis. Adm. Code, the following facilities owned or operated by the guaranteed party. The current cost estimates so guaranteed are shown for each facility: ____. The firm identified above is [insert one or more: (1) The direct or higher-tier parent corporation of the owner or operator; (2) owned by the same parent corporation as the parent corporation of the owner or operator, and receiving the following value in consideration of this guarantee____, or (3) engaged in the following substantial business relationship with the owner or operator ____, and receiving the following value in consideration of this guarantee____]. [Attach a written description of the business relationship or a copy of the contract establishing such relationship to this letter].

3. In States where EPA is not administering the financial requirements of subch. H of ch. NR 661, Wis. Adm. Code, this firm, as owner or operator or guarantor, is demonstrating financial assurance for the following facilities through the use of a test equivalent or substantially equivalent to the financial test specified in subch. H of ch. NR 661, Wis. Adm. Code. The current cost estimates covered by such a test are shown for each facility:____.

4. This firm is the owner or operator of the following hazardous secondary material management facilities for which financial assurance is not demonstrated either to EPA or a State through the financial test or any other financial assurance mechanism specified in subch. H of ch. NR 661, Wis. Adm. Code, or equivalent or substantially equivalent State mechanisms. The current cost estimates not covered by such financial assurance are shown for each facility:____.

5. This firm is the owner or operator of the following underground injection control facilities for which financial assurance for plugging and abandonment is required under part 144. The current closure cost estimates as required by 40 CFR 144.62 are shown for each facility:____.

6. This firm is the owner or operator of the following facilities for which financial assurance for closure or post-closure care is demonstrated through the financial test specified in subch. H of ch. NR 664 and subch. H of ch. NR 665, Wis. Adm. Code. The current closure and/or post-closure cost estimates covered by the test are shown for each facility: ____ .

7. This firm guarantees, through the guarantee specified in subch. H of ch. NR 664 and subch. H of ch. NR 665, Wis. Adm. Code, the closure or post-closure care of the following facilities owned or operated by the guaranteed party. The current cost estimates for the closure or post-closure care so guaranteed are shown for each facility: ____. The firm identified above is [insert one or more: (1) The direct or higher-tier parent corporation of the owner or operator; (2) owned by the same parent corporation as the parent corporation of the owner or operator, and receiving the following value in consideration of this guarantee; or (3) engaged in the following substantial business relationship with the owner or operator __, and receiving the following value in consideration of this guarantee __]. [Attach a written description of the business relationship or a copy of the contract establishing such relationship to this letter].

8. In States where EPA is not administering the financial requirements of subch. H of ch. NR 664 or subch. H of ch. NR 665, Wis. Adm. Code, this firm, as owner or operator or guarantor, is demonstrating financial assurance for the closure or post-closure care of the following facilities through the use of a test equivalent or substantially equivalent to the financial test specified in subch. H of ch. NR 664 and subch. H of ch. NR 665, Wis. Adm. Code,, Wis. Adm. Code. The current closure and/or post-closure cost estimates covered by such a test are shown for each facility: __.

9. This firm is the owner or operator of the following hazardous waste management facilities for which financial assurance for closure or, if a disposal facility, post-closure care, is not demonstrated either to EPA or a State through the financial test or any other financial assurance mechanism specified in subch. H of ch. NR 664 or subch. H of ch. NR 665, Wis. Adm. Code, or equivalent or substantially equivalent State mechanisms. The current closure and/or post-closure cost estimates not covered by such financial assurance are shown for each facility: __.

This firm [insert “is required” or “is not required”] to file a Form 10K with the Securities and Exchange Commission (SEC) for the latest fiscal year.

The fiscal year of this firm ends on [month, day]. The figures for the following items marked with an asterisk are derived from this firm’s independently audited, year-end financial statements for the latest completed fiscal year, ended [date].

[Fill in Alternative I if the criteria of sub. (5) (a) 1. of s. NR 661.0143, Wis. Adm. Code, are used. Fill in Alternative II if the criteria of sub. (5) (a) 2. of s. NR 661.0143, Wis. Adm. Code, are used.]

ALTERNATIVE I

1. Sum of current cost estimates [total of all cost estimates shown in the nine paragraphs above] $__

*2. Total liabilities [if any portion of the cost estimates is included in total liabilities, you may deduct the amount of that portion from this line and add that amount to lines 3 and 4] $__

*3. Tangible net worth $____

*4. Net worth $____-

*5. Current assets $____

*6. Current liabilities $____

7. Net working capital [line 5 minus line 6] $____

*8. The sum of net income plus depreciation, depletion, and amortization $____-

*9. Total assets in U.S. (required only if less than 90% of firm’s assets are located in the U.S.) $____-

10. Is line 3 at least $10 million? (Yes/No) ____

11. Is line 3 at least 6 times line 1? (Yes/No) ____-

12. Is line 7 at least 6 times line 1? (Yes/No) ____-

*13. Are at least 90% of firm’s assets located in the U.S.? If not, complete line 14 (Yes/No) ____

14. Is line 9 at least 6 times line 1? (Yes/No) ____-

15. Is line 2 divided by line 4 less than 2.0? (Yes/No) ____-

16. Is line 8 divided by line 2 greater than 0.1? (Yes/No) ____-

17. Is line 5 divided by line 6 greater than 1.5? (Yes/No) ____-

ALTERNATIVE II

1. Sum of current cost estimates [total of all cost estimates shown in the eight paragraphs above] $____-

2. Current bond rating of most recent issuance of this firm and name of rating service ____-

3. Date of issuance of bond ____-

4. Date of maturity of bond ____-

*5. Tangible net worth [if any portion of the cost estimates is included in “total liabilities” on your firm’s financial statements, you may add the amount of that portion to this line] $____-

*6. Total assets in U.S. (required only if less than 90% of firm’s assets are located in the U.S.) $____-

7. Is line 5 at least $10 million? (Yes/No) ____

8. Is line 5 at least 6 times line 1? (Yes/No) ____

*9. Are at least 90% of firm’s assets located in the U.S.? If not, complete line 10 (Yes/No) ____

10. Is line 6 at least 6 times line 1? (Yes/No) ____-

I hereby certify that the wording of this letter is identical to the wording specified in s. NR 661.0151 (5), Wis. Adm. Code, as such regulations were constituted on the date shown immediately below.

[Signature]

[Name]

[Title]

[Date]

NR 661.0151(6)(6) A letter from the chief financial officer, as specified in s. NR 661.0147 (6), shall be worded as follows, except that instructions in brackets are to be replaced with the relevant information and the brackets deleted:

Letter from Chief Financial Officer

[Address to Wisconsin Department of Natural Resources]

I am the chief financial officer of [firm’s name and address]. This letter is in support of the use of the financial test to demonstrate financial responsibility for liability coverage under s. NR 661.0147, Wis. Adm. Code, [insert “and costs assured s. NR 661.0143 (5), Wis. Adm. Code,” if applicable] as specified in subch. H of ch. NR 661, Wis. Adm. Code.

[Fill out the following paragraphs regarding facilities and liability coverage. If there are no facilities that belong in a particular paragraph, write “None” in the space indicated. For each facility, include its EPA Identification Number (if any issued), name, and address.]

The firm identified above is the owner or operator of the following facilities for which liability coverage for [insert “sudden” or “non-sudden” or “both sudden and non-sudden”] accidental occurrences is being demonstrated through the financial test specified in subch. H of ch. NR 661, Wis. Adm. Code:____

The firm identified above guarantees, through the guarantee specified in subch. H of ch. NR 661, Wis. Adm. Code, liability coverage for [insert “sudden” or “non-sudden” or “both sudden and non-sudden”] accidental occurrences at the following facilities owned or operated by the following: ____-. The firm identified above is [insert one or more: (1) The direct or higher-tier parent corporation of the owner or operator; (2) owned by the same parent corporation as the parent corporation of the owner or operator, and receiving the following value in consideration of this guarantee -____; or (3) engaged in the following substantial business relationship with the owner or operator ____-, and receiving the following value in consideration of this guarantee ____-]. [Attach a written description of the business relationship or a copy of the contract establishing such relationship to this letter.]

The firm identified above guarantees, through the guarantee specified in subch. H of ch. NR 664 and subch. H of ch. NR 665, Wis. Adm. Code, liability coverage for [insert “sudden” or “non-sudden” or “both sudden and non-sudden”] accidental occurrences at the following facilities owned or operated by the following: __. The firm identified above is [insert one or more: (1) The direct or higher-tier parent corporation of the owner or operator; (2) owned by the same parent corporation as the parent corporation of the owner or operator, and receiving the following value in consideration of this guarantee __; or (3) engaged in the following substantial business relationship with the owner or operator __, and receiving the following value in consideration of this guarantee __]. [Attach a written description of the business relationship or a copy of the contract establishing such relationship to this letter.]

[If you are using the financial test to demonstrate coverage of both liability and costs assured under s. NR 661.0143 (5), Wis. Adm. Code, or closure or post-closure care costs under s. NR 664.0143, 664.0145, 665.0143 or 665.0145, Wis. Adm. Code, fill in the following nine paragraphs regarding facilities and associated cost estimates. If there are no facilities that belong in a particular paragraph, write “None” in the space indicated. For each facility, include its EPA identification number (if any issued), name, address, and current cost estimates.]

2. This firm guarantees, through the guarantee specified in subch. H of ch. NR 661, Wis. Adm. Code, the following facilities owned or operated by the guaranteed party. The current cost estimates so guaranteed are shown for each facility:____. The firm identified above is [insert one or more: (1) The direct or higher-tier parent corporation of the owner or operator; (2) owned by the same parent corporation as the parent corporation of the owner or operator, and receiving the following value in consideration of this guarantee____, or (3) engaged in the following substantial business relationship with the owner or operator ____, and receiving the following value in consideration of this guarantee____]. [Attach a written description of the business relationship or a copy of the contract establishing such relationship to this letter].

5. This firm is the owner or operator of the following underground injection control facilities for which financial assurance for plugging and abandonment is required under 40 CFR part 144. The current closure cost estimates as required by 40 CFR 144.62 are shown for each facility:____.

7. This firm guarantees, through the guarantee specified in subch. H of ch. NR 664 and subch. H of ch. NR 665, the closure or post-closure care of the following facilities owned or operated by the guaranteed party. The current cost estimates for the closure or post-closure care so guaranteed are shown for each facility: ____. The firm identified above is [insert one or more: (1) The direct or higher-tier parent corporation of the owner or operator; (2) owned by the same parent corporation as the parent corporation of the owner or operator, and receiving the following value in consideration of this guarantee ____; or (3) engaged in the following substantial business relationship with the owner or operator ____, and receiving the following value in consideration of this guarantee ____.]

[Attach a written description of the business relationship or a copy of the contract establishing such relationship to this letter].

8. In States where EPA is not administering the financial requirements of subch. H of ch. NR 664 or subch. H of ch. NR 665, this firm, as owner or operator or guarantor, is demonstrating financial assurance for the closure or post-closure care of the following facilities through the use of a test equivalent or substantially equivalent to the financial test specified in subch. H of ch. NR 664 and subch. H of ch. NR 665. The current closure and/or post-closure cost estimates covered by such a test are shown for each facility: ____.

9. This firm is the owner or operator of the following hazardous waste management facilities for which financial assurance for closure or, if a disposal facility, post-closure care, is not demonstrated either to EPA or a State through the financial test or any other financial assurance mechanism specified in subch. H of ch. NR 664 and subch. H of ch. NR 665 or equivalent or substantially equivalent State mechanisms. The current closure and/or post-closure cost estimates not covered by such financial assurance are shown for each facility: ____.

This firm [insert “is required” or “is not required”] to file a Form 10K with the Securities and Exchange Commission (SEC) for the latest fiscal year.

Part A. Liability Coverage for Accidental Occurrences