CERTIFIED AND INSURED PRESCRIBED BURN MANAGER
INSURANCE VERIFICATION FORM
Section 153.082 of the Texas Natural Resources Code provides:
The limitation on liability under Section 153.081 does not apply to an owner, lessee, or occupant of
agricultural land unless the certified and insured prescribed burn manager conducting a burn on the land
has liability insurance coverage:
(1) of at least $1 million for each single occurrence of bodily injury or death, or injury to or destruction of
property; and
(2) with a policy period minimum aggregate limit of at least $2 million.
4 TAC §227.1 provides:
“The certified and insured prescribed burn manager conducting a prescribed burn shall carry or be covered
by:
(1) at least $1 million of liability insurance coverage for each single occurrence of bodily injury to or
destruction of property; and
(2) with a policy period minimum aggregate limit of at least $2 million.”
4 TAC §227.1
“Documentation as required by Sec. 227.1 (e) of this title (relating to Insurance Requirements) shall be
provided to the Board annually to show proof of insurance on or before December 31
st
. Failure to provide
timely proof of insurance shall render certification invalid. Documentation for any limiting scope of the
applicable insurance must be provided. Any limitation on coverage shall be disclosed. The following is
considered valid documentation:
(1) Certificate of insurance from insurance company;
(2) A letter certifying existence of a fund program or a program of self-insurance a governmental unit; or
(3) any other documentation approved by the Board.”
The Board has approved this verification form as the method of providing proof of insurance.
Insured Information:
Name _______________________________________ License No. _____
Address _____________________________________ Check here if you
wish to make a
_____________________________________________ change of address.
Phone Number ________________________________
E-Mail _______________________________________
I hereby certify that I am covered by a liability insurance policy which complies with the
requirements of Section 153.082 of the Texas Natural Resources Code and 4 TAC Section
227.1.
____ There has been no change to my insurance policy since it was last approved.
_____ My policy has changed since it was last approved. A copy of the new policy is attached.
YOU MUST ATTACH A COPY OF YOUR NEW POLICY IF IT HAS CHANGED IN ANY WAY.
___________________________________________________
Signature Date
Please mail to: Texas Department of Agriculture, Prescribed Burn Program, P.O. Box 12847, Austin, TX
78711-2847 or fax to 800-909-8534.
