Certificate of Financial Responsibility

Please search for one of the owner's facilities to get a list of all the facilities owned by that owner.

Instruction Guide
required
Owner - New Information


required

If the above owner name is not correct, please do not submit this form until you have submitted a Notification for Underground Storage Tanks to change the ownership.

Please indicate below the facilities for which you are reporting by checking the box(es) below. Check the "Select All" box to select all facilities listed.

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Facility # Name Address City

The Office of the Illinois State Fire Marshal, Division of Petroleum and Chemical Safety is requesting information regarding financial responsibility that is being maintained by owners or operators for underground storage tanks they currently own. Section 176.210 of the Office of the State Fire Marshal rules and regulations states that each owner or operator shall maintain financial responsibility in the sum of $20,000, regardless of the number of USTs or facilities owned or operated. This $20,000 shall be comprised as follows:

  1. $10,000 for corrective action; and
  2. $10,000 for third-party liability for bodily injury or property damage (for definitions of "bodily injury" or "property damage" see 415 ILCS 5/57.2).

DO NOT include information of a personal or private nature on supplemental documents submitted with this Financial Responsibility Report Form. Examples of this type of information include but are not limited to: Social Security Numbers, Bank Account Numbers, Personal Addresses, Personal Phone Numbers, Personal Email Addresses, Dates of Birth, or any other personal or private information. If any such information is included on supplemental documentation attached to the Financial Responsibility Report Form, we will redact that information before filing the document in our agency database in order to protect your privacy interests.

NOTE: This action is authorized by formal OSFM policy that requires protection of private confidential information in OSFM regulatory activities and which limits employee access to only those who have the need to have access to such information. It is therefore an exception to the State records act, being action that is required under the OSFM policy implementing state and federal laws that protect the confidentiality of private information.

Please indicate below the type of financial assurance that you as the owner/operator are maintaining for the underground storage tanks at the above-referenced facilities.



(See below for additional requirements.)
Attach a letter signed by the owner’s Chief Financial Officer (unless State or Federal owned)
(Date must coincide with financial statement provided.)
Attach financial statement, statement summaries, or statement abstracts (unless State or Federal owned)

(See below for additional requirements.)

(Required: Send original surety bond document to OSFM within 60 days)

(Required: Send original letter of credit document to OSFM within 60 days)



OSFM does not require submission of supporting documents with the Financial Responsibility Report unless a facility is reporting Self-Insurance as their Financial Responsibility mechanism. For Self-Insurance reporting, follow the instructions for supporting documentation below in "Requirements." Documents supporting Financial Responsibility mechanisms other than Self-Insurance, Surety Bonds, and Letters of Credit shall be kept by the owner/operator.
Mailing address: Office of the Illinois State Fire Marshal, Division of Petroleum & Chemical Safety, 1035 Stevenson Dr., Springfield, IL, 62703

I certify under penalties as provided by law pursuant to Section 1-109 of the Code of Civil Procedure that I am authorized to make this disclosure, that I have authority to execute this instrument on behalf of the owner/operator, and that I have personally examined and am familiar with the information submitted in this document, and that based on my inquiry of those immediately responsible for obtaining information, I affirm that the submitted information is true, accurate and complete.



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    FINANCIAL RESPONSIBILITY MECHANISM REQUIREMENTS

    Any financial responsibility obtained must be in the sum of $20,000.00 comprised as follows:


    (1) $10,000 per occurrence for corrective action.

    (2) $10,000 per occurrence for 3rd party liability for bodily injury or property damage. See 41 Il. Adm. Code 176.210.

    Commercial or Private Insurance – Owners or Operators must obtain liability insurance from a qualified insurer or risk retention group. Such insurance may be in the form of a separate insurance policy or an endorsement to an existing insurance policy. This policy must specifically cover costs of corrective action needed as a result of: 1) environmental damage, 2) third party bodily injury and 3) third party property damage caused by pollution as a result of a release from Underground Storage Tanks (USTs). (40 CFR 280.97, incorporated in Section 176.210)

    Self-Insurance - To qualify as a self insurer, Section 176.220 of the Office of the State Fire Marshal Rules and Regulations states in part that owners or operators must demonstrate a net worth equal to or in excess of $200,000. To meet the requirements of using self-insurance, an owner or operator must submit the following documentation to the Office of the State Fire Marshal:

    (1) The annual notification indicating the financial responsibility mechanism chosen;

    (2) Letter signed by the owner’s Chief Financial Officer attesting to a tangible net worth equal to or greater than $200,000, as shown by attached financial statements, statement summaries, or statement abstracts, prepared by an independent certified public accountant. See 40 CFR 280.95 (d) for how the letter must be worded.

    (3) Copies of financial statements, a financial statement summary, or a financial statement abstract for the most recent fiscal year, prepared by an independent certified public accountant, to be on file with OSFM not later than 180 days after the close of the financial reporting year and showing tangible net worth equal to or greater than $200,000. OSFM encourages submission of the summary document or abstract of financial statements in lieu of the full financial statements, but that is up to the individual facility owner or operator.

    Guarantee – The guarantor must be a firm that possesses a controlling interest in the owner or operator; possesses a controlling interest in the firm; or is controlled through stock ownership by a common parent firm that possesses a controlling interest in the owner or operator, and must be able to demonstrate tangible net worth of at least $200,000. See 40 CFR 280.96 (c) for how the guarantee must be worded.

    Surety Bond – The surety company issuing the bond must be among those listed as acceptable sureties on federal bonds in the latest Circular 570 of the U.S. Department of the Treasury. See 40 CFR 280.98 (b) for how the surety bond must be worded.

    Letter of Credit – Must obtain an irrevocable standby letter of credit. The issuing institution must be an entity that has authority to issue letters of credit in each state where used and whose letter-of-credit operations are regulated and examined by a federal or state agency. See 40 CFR 280.99 (b) for how the irrevocable standby letter of credit must be worded.

    Certificate of Deposit – A certificate from a bank stating that the named party (owner/operator) has a specified sum ($20,000.00) on deposit.

    Designated Savings Account – A savings account that is specifically setup for meeting the financial responsibility requirements of $20,000. This account cannot be used for any other purpose.