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Form 23447 -Certificate Of Insurance

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Indiana Grain Buyers & Warehouse

CERTIFICATE OF INSURANCE

OFFICE USE ONLY

Licensing Agency

State Form 23447 (R4 / 10-07)

101 West Ohio Street

INDIANA STATE DEPARTMENT OF AGRICULTURE

Suite 1200

File #:

Indianapolis, Indiana 46204

Telephone: (317) 232-1356 FAX: (317) 232-1362

ISSUED BY: (name of insurance company)

Home office address: (number and street, city, state, ZIP code)

THIS IS TO CERTIFY THAT there is now in effect an insurance policy(ies) issued by this company, policy number(s) as listed

below, insuring all grain contained, in the name of the indicated business firm against loss by fire, internal explosion, lightning,

and windstorm.

Name of insured business firm:

Monthly reporting required?

Yes

Headquarters address: (number and street, city, state, ZIP code)

Can we send unofficial communications via email?

Email Address:

Yes

LIMIT OF LIABILITY

EFFECTIVE

EXPIRATION

POLICY NO.

NAME & LOCATION OF INSURED FACILITY

FOR GRAIN

POLICY DATE

This certificate is furnished as a matter of information only and covers no rights upon the holder. It is issued with the understanding

that the rights and limitations of the parties will be governed by the original policy as it may be lawfully amended by endorsement from

time to time. Insurance is afforded only with respect to such and so many of the above policies and coverages thereunder as are

stated therein, subject to all terms of the policy having reference thereto.

This further certifies that, pursuant to Ind. Code § 26-3-7-14, the Company will not cancel or reduce the limit of liability of the above

listed policy(ies) except after the expiration of a thirty (30) day period from the mailing, by certified mail, of notice of intent to cancel, to

the Director of the Indiana Grain Buyers and Warehouse Licensing Agency. A copy of such notice will be mailed to the entity

referenced on the policy and licensed under IC 26-3-7, et seq., at the time of giving notice to the Director. The cancellation or

reduction in the limit of liability shall not affect the liability accrued or which may accrue under such insurance policy before the

expiration of the thirty-day period.

It is understood that the licensed entity that is insured may not cancel or reduce the limits of the policy(ies) listed above without the

prior written approval of the Director of the Indiana Grain Buyers and Warehouse Licensing Agency, and the Director’s receipt and

approval of a substitute cash deposit or approval of a substitute bond or insurance.

Signature of Licensed agent:

CERTIFICATE HOLDER:

Director, Indiana Grain Buyers &

Date of issue of certificate:

Warehouse Licensing Agency

Form 23447 -Certificate Of Insurance

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