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PMMIC Insurance Petroleum Marketers Mutual Insurance Company
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Forms

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APPLYING FOR COVERAGE

APPLICATION FOR COVERAGE - AST
(Application for coverage to meet financial responsibility requirements for new AST applicants.)
APPLICATION FOR COVERAGE - UST
(Application for coverage to meet financial responsibility requirements for new UST applicants.)
APPLICATION FOR COVERAGE - UST
(Application for coverage to meet financial responsibility requirements for "previously insured" UST sites.)
CERTIFICATION OF KNOWN PETROLEUM CONTAMINATION
HOW DO I APPLY?
HOW TO ANALYZE YOUR SITE
How to analyze your site for petroleum contamination.
MARINA CHECKLIST
(for new sites applying for coverage)
METHODS OF LEAK DETECTION
OWNERSHIP BACKGROUND INFORMATION
RENEWAL APPLICATION
 

CLAIMS

CLAIM ASSIGNMENT FORM (new)
INSURANCE CLAIM FORM
PMMIC CLAIMS PROCEDURES
REPORTING CLAIMS
 

INSPECTIONS

AUTHORIZATION TO RELEASE INSPECTION INFO TO IDNR
FREQUENT WALK-THROUGH INSPECTIONS
 

MONITORING

CATHODIC PROTECTION MONITORING LOG
GROUNDWATER OR VAPOR MONITORING LOG
LINE LEAK DETECTION LOG
METHODS OF LEAK DETECTION
PMMIC LINE LEAK DETECTION LOG
Secondary Containment with Interstitial Monitoring
PMMIC LINE LEAK DETECTION LOG
PMMIC Line Leak Detection Log INCON / Campo Miller
PMMIC TANK LEAK DETECTION LOG
Secondary Containment with Interstitial Monitoring
PMMIC TANK LEAK DETECTION LOG
Temporary ATG Leak Test Report
PMMIC TEST REPORTING FORM
Red Jacket PPM-4000/RLM-9000 Annual Line Test & Electronic Line Leak Detector
 

MISCELLANEOUS POLICY FORMS

ATG CERTIFICATION FORM
CERTIFICATION OF TOTAL CONTAINMENT PIPING REPLACEM
DOCUMENTATION OF OVERFILL PREVENTION IN UST SYSTEM
NOTIFICATION OF CONTRACTUAL AGREEMENT -PIPING
NOTIFICATION OF SITE WORK
UST SYSTEM COMPATIBILITY ASSESSMENT FORM
PMMIC PREMIUM CREDIT FORM
 

IDNR & EPA FORMS

IDNR 148 FORM-NEW
IDNR CATHODIC PROTECTION INSPECTION FORM
IDNR ETHANOL CHECKLIST
IDNR ETHANOL CONVERSION
IDNR ETHANOL INSPECTION FORM
IDNR TEMPORARY CLOSURE FORM
IDNR INSTALLER INSPECTOR CHECKLIST
IDNR NOTIFICATION OF INTENT TO INSTALL
IDNR FLOOD CERTIFICATION FORM.2008
IDNR RETURN TO SERVICE FORM
NESHAP NOTIFICATION FOR GASOLINE DISPENSING FACILITIES (GDF)
IDNR CHANGE OF OWNERSHIP FORM
 

PMMIC POLICIES & NOTICES

PMMIC POLICY (AST) 2007
PMMIC POLICY (UST) 2005
PMMIC PRIVACY NOTICE
 

POLICY CHANGES & AUTHORIZATIONS

ADDITIONAL INSUREDS
Additions / Deletions
AUTHORIZATION TO RELEASE INFORMATION TO IDNR
AUTHORIZATION TO RELEASE POLICY INFORMATION
ID NUMBER CHANGE REQUEST
PREMIUM INVOICE - ADDITIONAL INSURED
REQUEST FOR CANCELLATION OF PMMIC POLICY
 
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R & A - Rounds & Associates
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2894 - 106th St., PO Box 7628, Urbandale, Iowa 50323 All rights reserved.
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