OHIO DEPARTMENT OF AGRICULTURE

Division of Plant Industry - Grain & Seed Section

8995 East Main Street

Reynoldsburg, OH 43068-3399

(614) 728-6410

DIVISION:

Web FORM:

Last Revised:

FORM EXPIRES:

PLNT-GS

4203-004

02/27/2004

12/31/2004

CERTIFICATE OF INSURANCE

This is to certify that:
	(Name of Agency)
	(Address) (City) (State) (Zip Code) (County)
	(Telephone Number with Area Code)
has issued to:
	(Name of Assured)
	(Address) (City) (State) (Zip Code) (County)
Fire and Extended Coverage Insurance on stocks of grain subject to the terms, conditions and exclusions of the policy or policies listed hereon, and that said insurance is in force on the date this certificate is issued on property located at:

CODE NUMBER (*)	POLICY NUMBER	EFFECTIVE DATE	EXPIRATION DATE	INSURANCE IN FORCE ON GRAIN INVENTORY	IF CO-INSURANCE, WHAT PERCENT?

(*) Use Code Number, such as (1), (2), (3), for carrier(s) issuing policy. List below by corresponding code number the name and address of the carrier(s).

Loss Payable to: OHIO DEPARTMENT OF AGRICULTURE, 8995 EAST MAIN STREET, REYNOLDSBURG, OH 43068-3399
The above policies shall contain a clause granting a lien in favor of the state for the benefit of the depositors of agricultural commodities in such warehouse, as their interests may appear on the records of the warehouseman. In the event any policy described above is cancelled, not renewed, or the amount of coverage is changed, written notice of such change shall be mailed to the addressee in compliance with Section 926.07 (a) and 926.09 of the Revised Code.

		(Name of Insurance Company)
		(By)
(Date)		(Title)