RAILROAD COMMISSION OF TEXAS
Oversight and Safety Division
Alternative Fuels Safety Department
STATEMENT IN LIEU OF GENERAL LIABILITY INSURANCE
AND/OR COMPLETED OPERATIONS OR PRODUCTS LIABILITY
INSURANCE
Please Type or Print
LPG F
ORM
998B
I, ,
(Name of Person Completing Statement) (Title)
do make this statement that is licensed or applying for
(Name(s) under which LP-gas licensee is or will be operating)
license pursuant to Section 113.082, Texas Natural Resources Code, Chapter 113, as a category dealer, that said applicant or
(category)
dealer is not engaging in any LP-gas operations and, consequently, is filing this statement in
(effective date)
lieu of certificate of:
Check the appropriate box (es)
general liability insurance. The licensee or applicant for a license must file the required insurance certificate with the section
before engaging in any operations that requires general liability insurance.
completed operations and products liability insurance. The licensee or applicant for a license must file the required insurance
certificate with the division before engaging in any operations that requires completed operations and products liability operations
insurance.
The applicant states that prior to performance of any activities which requires general liability coverage, and completed operations &
product liability as set forth in the Texas Natural Resources Code, Chapter 113, or the LP-Gas Safety Rules, the applicant will procure
the insurance as required by the Code and LP-Gas Safety Rules and will submit proof of such insurance to Alternative Fuels
Safety.
THE STATE OF :
COUNTY OF:
I declare under penalties prescribed in Section 91.143, Texas Natural Resources Code, I am authorized to make this statement; I
have personal knowledge of the above-stated facts; this statement was prepared by me or under my supervision and direction, and
the data and facts stated herein are true, correct, and complete to the best of my knowledge.
(Printed Name)
(Signature)
(Area Code/Telephone Number) (Date)
Return to:
Railroad Commission of Texas
Alternative Fuels Safety
P.O. Box 12967
Austin, Texas 78711-2967
800-64-CLEAR
Fax (512) 463-7292
Rev. January 2020
LPG FORM 998B
RRC USE ONLY
Reviewed by:
Date:
