FS-2700-33 Insurance Endorsement Special Use Authorization

USDA Forest Service FS-2700-33 (09/2020)

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.  Response to this collection of information is mandatory. The authority to collect the information is the Organic Administration Act,16 U.S.C. 551.  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.

   

In accordance with Federal civil rights law and U.S. Department of Agriculture (USDA) civil rights regulations and policies, the USDA, its Agencies, offices, and employees, and institutions participating in or administering USDA programs are prohibited from discriminating based on race, color, national origin, religion, sex, gender identity (including gender expression), sexual orientation, disability, age, marital status, family/parental status, income derived from a public assistance program, political beliefs, or reprisal or retaliation for prior civil rights activity, in any program or activity conducted or funded by USDA (not all bases apply to all programs).  Remedies and complaint filing deadlines vary by program or incident.

Persons with disabilities who require alternative means of communication for program information (e.g., Braille, large print, audiotape, American Sign Language, etc.) should contact the responsible agency or USDA’s TARGET Center at (202) 720-2600 (voice and TYY) or contact USDA through the Federal Relay Service at (800) 877-8339.  Additionally, program information may be made available in languages other than English.

To file a program discrimination complaint, complete the USDA Program Discrimination Complaint Form, AD-3027, found online at How to File a Program Discrimination Complaint and at any USDA office or write a letter addressed to USDA and provide in the letter all of the information requested in the form.  To request a copy of the complaint form, call (866) 632-9992.  Submit your completed form or letter to USDA by: (1) mail: U.S. Department of Agriculture, Office of the Assistant Secretary for Civil Rights, 1400 Independence Avenue, SW, Washington, D.C. 20250-9410; (2) fax: (202) 690-7442; or (3) email: [email protected]. 

USDA is an equal opportunity provider, employer, and lender.

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.

Page 1 of 3