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Get TX ALS-1101 2015-2024

US TEXAS DEPARTMENT OF AGRICULTURE ALS-1101 STRUCTURAL PEST CONTROL SERVICE CERTIFICATE OF INSURANCE COM M ISSIONER SID M ILLER The policy identified in Section C has been issued by the insurer identified in Section B and insures the structural pest control business licensee identified in Section A against liability for damage to persons or property occurring as a result of operations performed in the course of the business of structural pest control on premises or any other property under the applicant s care custody or control in an amount not less than 200 000 for bodily injury and property damage coverage with a minimum total aggregate of 300 000 for all occurrences. P. O. BOX 12847 AUSTIN TEXAS 78711 877 542-2474 512 463-7476 HEARING IMPAIRED 800 735-2988 VOICE WWW*AGR*STATE*TX. SECTION A Full Legal Business Name DBA if applicable TDA License No* Or TPCL No* Physical Address City State Zip INSURER INFORMATION Name of Insurance Company Mailing Address Phone - Email Address SEC. C POLICY INFORMATION Policy No* Policy Effective Date / Policy Expiration Date mm/dd/yyyy CERTIFICATION AND SIGNATURE I hereby certify that 1 the statements and information on this form are true and accurate to the best of my knowledge 2 I am a licensed Texas insurance agent or the insurer s representative authorized to sign on behalf of the insurer identified above and 3 the insurer identified above is authorized to do business in the State of Texas. Name of Insurer s Representative or Agent Signature of Insurer s Representative or Agent and Date Texas License Number if agent signs Please email the completed and signed form to insurance texasagriculture. gov This Certificate of Insurance is issued for informational purposes only does not confer any rights or obligations other than the rights and obligations conveyed by the policy referenced herein and the terms of said policy shall control over the terms herein* REVISED 1/1/2015. SECTION A Full Legal Business Name DBA if applicable TDA License No* Or TPCL No* Physical Address City State Zip INSURER INFORMATION Name of Insurance Company Mailing Address Phone - Email Address SEC. C POLICY INFORMATION Policy No* Policy Effective Date / Policy Expiration Date mm/dd/yyyy CERTIFICATION AND SIGNATURE I hereby certify that 1 the statements and information on this form are true and accurate to the best of my knowledge 2 I am a licensed Texas insurance agent or the insurer s representative authorized to sign on behalf of the insurer identified above and 3 the insurer identified above is authorized to do business in the State of Texas. C POLICY INFORMATION Policy No* Policy Effective Date / Policy Expiration Date mm/dd/yyyy CERTIFICATION AND SIGNATURE I hereby certify that 1 the statements and information on this form are true and accurate to the best of my knowledge 2 I am a licensed Texas insurance agent or the insurer s representative authorized to sign on behalf of the insurer identified above and 3 the insurer identified above is authorized to do business in the State of Texas. Name of Insurer s Representative or Agent Signature of Insurer s Representative or Agent and Date Texas License Number if agent signs Please email the completed and signed form to insurance texasagriculture. .

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