FS-2700-33 Insurance Endorsement Special Use Authorization

USDA Forest Service FS-2700-33 (03/06)

OMB No. 0596-0082

Authorization ID      

Contact ID      

Expiration Date      

INSURANCE ENDORSEMENT

SPECIAL USE AUTHORIZATION

FOR [holder or applicant name]

<Delete Instructions prior to printing>

<This form may be used to designate the United States Government as additional insured for commercial general liability coverage or commercial property coverage.>

POLICY NUMBER       COMMERCIAL GENERAL LIABILITY

THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.

ADDITIONAL INSURED –

UNITED STATES GOVERNMENT – AUTHORIZATIONS

This endorsement modifies insurance provided under the following:

COMMERCIAL GENERAL LIABILITY COVERAGE PART.

COMMERCIAL PROPERTY COVERAGE PART.

SCHEDULE

United States Government Agency:

USDA Forest Service

[name] National Forest

[mailing address of administering office]

[city, state, zip code]

(If no entry appears above, information required to complete this endorsement will be shown in the Declarations as applicable to this endorsement.)

WHO IS AN INSURED (Section II) is amended to include as an insured the United States Government acting by and through the United States Government agency shown in the Schedule, subject to the following provisions:

1. This insurance applies solely as respects liability arising from operations of the named insured for which the U.S. Government agency has issued an authorization.

2. This insurance will not be changed or its provisions altered or deleted before thirty (30) days written notice is given to the U.S. Government agency shown in the Schedule.

Signature ______________________________________

Authorized Representative of Issuing Company

Date ______________________________________

According to the Paperwork Reduction Act of 1995, an agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0596-0082. The time required to complete this information collection is estimated to average 15 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. The U.S. Department of Agriculture (USDA) prohibits discrimination in all its programs and activities on the basis of race, color, national origin, gender, religion, age, disability, political beliefs, sexual orientation, and marital or family status. (Not all prohibited bases apply to all programs.) Persons with disabilities who require alternative means for communication of program information (Braille, large print, audiotape, etc.) should contact USDA’s TARGET Center at 202-720-2600 (voice and TDD).

To file a complaint of discrimination, write USDA, Director, Office of Civil Rights, 1400 Independence Avenue, SW, Washington, DC 20250-9410 or call (800) 975-3272 (voice) or (202) 720-6382 (TDD). USDA is an equal opportunity provider and employer.

The Privacy Act of 1974 (5 U.S.C. 552a) and the Freedom of Information Act (5 U.S.C. 552) govern the confidentiality to be provided for information received by the Forest Service.