WASTE & RECYCLING PROPOSAL FORM

Transcription

1 WASTE & RECYCLING PROPOSAL FORM

2 WASTE & RECYCLING MATERIAL DAMAGE PROPOSAL FORM Please Complete in Block Capitals and Tick Appropriate Boxes Where Relevant, if answers are Not Applicable, please write N/A Please also provide the following supplementary information: (a) Site Plan (Identifying use of individual buildings/areas) (b) Photographs of the premises (Internal and External) (c) A separate Questionnaire for each additional location Full Name of Proposer: Address: Post Code: Website: Daytime Business Telephone: Renewal Date of Policy: Existing Insurers and Policy No: 1 Specify your full description of Trade/Business including all processes undertaken (if you have a brochure, company literature or web address please attach them to this form) Sorting:Yes No Granulating:Yes No Shredding:Yes No Baling:Yes No Other:Yes No Other processes please specify: Please detail the approx. percentages of incoming waste streams typically handled: Construction & Demolition % Green / Garden/ Composting % Glass % Bricks/rubble/soil % Commercial & Industrial inc Food % Pure Wood Wastes % Commercial & Industrial ex Food % Pure Food Wastes % Domestic (Black Bag) % End of life Vehicles % Paper & Cardboard % Rubber / Tyres % Plastics % WEEE (Waste Electronic Electrical Equipment % Textiles & Clothing % Fridges / Freezers % Aggregate / Glass % Batteries % Liquid (Non Hazardous) % Used Engine Oil/Solvents % Liquid (Hazardous) % Clinical / Sharps % Metals and Cans % Total (100) % Other % 2

3 Address of location to be Insured: NB: Please complete a separate proposal form for each location) Are you the Owner of the Buildings at the premises? Yes No Are the premises in a good state of repair and is all plant and machinery in good order? Yes No Are the premises detached and separated from any adjoining premises? Yes No If No, please describe occupancy of adjoining premises: Are you the Sole Occupier or Tenant of the Buildings at the premises? Yes No If No, please provide Full details of other occupants and their Trades/Business Other Occupant 1 Other Occupant 2 Other Occupant 3 Trade Trade Trade 2 If the premises are let to tenants please confirm if a tenancy agreement is in force Yes No 3 Date you commenced trading: (a) At these premises (b) Elsewhere 4 Is the Business VAT registered Yes No 5 Has the business changed name in the last 5 years? Yes No if yes please provide full details of all previous names 6 Please provide details of the Insured s customer turnover? 3

4 DESCRIPTION OF PROPERTY AND TRADING ARRANGEMENTS (a) Approximate age of construction (b) Number of storeys Construction of: (c) Walls (For Example please state - brick, stone, concrete, metal, composite panels or sheets composed entirely of incombustible mineral ingredients, timber, etc) (d) Roof (For Example please state does the external surface of the roof consist of slates, tiles, metal, concrete, sheets or slabs composed entirely of incombustible mineral ingredients, felt, asphalt, bitumen, timber, etc) (e) Flooring (For Example - concrete, stone, timber, etc) (f) Ceiling & Linings (For Example - plasterboard, timber, etc) (g) Is any part of the roof area flat Yes No If Yes, please give details and percentage of roof area (h) Is any part of the premises constructed using Composite Panels (metal faced with Yes / No insulation) Yes No If Yes, please give details of the type (i) Hours and Days of Operation: (this is the time when the building / business is open for normal operation, not including the time when only maintenance, housekeeping or security staff may be in the building and or at the premises) (j) Are flammable liquids, gases or hazardous chemicals used or stored? Yes No Please describe arrangements for handling & storage of any flammable liquids, gases, or other special hazards (k) Have you carried out a Fire Risk Assessment within the last 12 months in respect of each location to be insured? Yes No 4

5 If No, please give details 2 Is combustible material and/or waste stored outside within 10 metres of any building or outbuilding? Yes No If Yes, please give Full details including measures to prevent spread of fire to buildings: 3 Are any non-fixed or portable heaters used including space heaters and alike? Yes No If Yes, please give details of protections incorporated to the same to prevent spread of fire: 4 Please provide a copy of your current Institution of Engineering and Technology (IET) Certificate (Fixed Wiring Certificate) Please state the date of the last inspection by a qualified electrical engineer 5 (a) Is the Property in an area which has any history of flooding? Yes No If Yes, please detail (b) Is the property situated near a river, stream, reservoir, lake? Yes No DESCRIPTION OF FIRE EXTINGUISHING APPLIANCES, SUPPRESSION AND DETECTION 1 (a) Where is the nearest Fire Brigade and how far away is it? (b) Is the operation of the nearest Fire Brigade Full Time Part- Time 2 Is there Fire Detection and Alarm System within processing and storage areas of the premises? Yes No (a) If Yes, advise name of Installer and which Trade Association they are Members of (b) Please advise the type of signaling of the Fire Detection and Alarm System, if any: Audible only / Digital Communicator to Central Station / RedCare / Dualcom / Other (please delete as applicable) If Other please give details: (c) Is the Fire Alarm maintained under contract and will it continue to be so? Yes No 3 Are hose reels fitted, if so are they near critical machinery? Yes No 5

6 4 Are all fire extinguishers and/or hose reels maintained under contract and will it continue to be so? Yes No 5 Is smoking prohibited on the premises? Yes No If No, please describe smoking arrangements on site: 6 Distance to nearest fire hydrant metres 7 If over 250metres, is there a suitable alternative water source available?( I.e River/lake) Yes No If yes, please give details below 8 Are there sprinklers in the process and storage buildings Yes No 9 Please advise which edition the sprinkler system is (BS5306) 10 Is the sprinkler system serviced annually by a qualified sprinkler engineer Yes No DESCRIPTION OF SECURITY ARRANGEMENTS 1 Are the premises completely enclosed by fencing and is the entrance by controlled gates? Yes No If No, please give details 2 Is there an Intruder Alarm at the premises? Yes No If Yes, advise name of Installer (c) Please advise the type of signalling on the Intruder Alarm, and attach a copy of the installer s specification. Audible only Digital Communicator to Central Station RedCare / Dualcom Is the Intruder Alarm maintained by the Installer and will it continue to be so? Yes No 3 Are the premises fitted with a CCTV System? Yes No If Yes is the system: a) Monitored by a 3rd party security company outside normal hours of operation Yes No b) Monitored and recorded onsite at all times Yes No c) Monitored during normal hours of operation and recorded onsite at all times Yes No d) Recorded onsite at all times (no monitoring) Yes No e) Other, please specify If recorded onsite, please detail a) the length of time that CCTV footage is kept for: b) the arrangements in place to prevent loss of data through theft, fire or any other cause: 6

7 Is the CCTV recording unit kept in a separate buildings to the process/ storage buildings? Yes No Is the CCTV recording unit kept at least 10 metres from any process / storage buildings? Yes No Is the CCTV recording unit kept within a 1 hour (minimum) rated fire proof box? Yes No Does the coverage provided by the CCTV system include all processing and storage areas onsite? Yes No 4 Are the premises guarded when unoccupied by an onsite security guard? Yes No Is the security guard a) third party registered security contractor b) own member of staff Please detail arrangements in place to ensure regular foot patrols are undertaken, ie tag point system / log DESCRIPTION OF PLANT AND MACHINERY 1 Is Plant and Machinery maintained in accordance with manufacturer s guideline? Yes No 2 Are all maintenance records documented for all fixed and mobile plant? Yes No 3 Is Plant and Machinery under an annual maintenance contract? Yes No 4 Are formal documented maintenance records maintained? Yes No 5 Is the machinery cleaned on a regular basis to avoid build up of dust / fly? Yes No DESCRIPTION OF SHREDDING ACTIVITIES ONSITE 1 Do you undertake any shredding activities onsite? Yes No If Yes, please provide a site plan showing area(s) used and answer the additional questions below 2 Do any shredding activities take place inside any buildings? Yes No If Yes, please give full details and types of waste shredded 3 Please detail make(s) and model(s) of all shredding equipment 4 Is post shredded waste segregated and monitored for sources of heat / ignition? Yes No 5 Do any shredding activities take place onsite outside of the buildings? Yes No If Yes, please give full details and types of waste shredded 7

8 6 Please detail make(s) and model(s) of all shredding equipment 7 Is post shredded waste segregated and monitored for sources of heat / ignition? Yes No 8 Do you cease shredding activities at least 2 hrs before close of business? Yes No If No, what procedures do you have to detect ignition / heat sources in post shredded material after hours: DESCRIPTION OF KEY PROCESS PLANT & MACHINERY ONSITE 1 Specify all key Process Plant and Machinery valued over 50,000 including full description/make and model/age/value Description (make and model) Value Age Lead time for replacement machiner 2 Is any Process Plant and Machinery fitted with Automatic Fire Suppression systems? Yes No If Yes, please give details of systems installed, including installers, ie Fireward 3 Is any Process Plant and Machinery fitted with spark detection systems? Yes No If Yes, please give details of systems installed, including installers, i.e. Grecon 4 Is any combustible material kept within 6 metres of any key process plant and machinery once the business is closed Yes No for daily operations? 5 Can the fixed electrical key process machinery be isolated back to the mains when not in use? Yes No 6 Is key process plant and machinery cleared of combustible material before the end of daily operations Yes No (Trommel Feeds, Bailers, Shredders, Picking Station Bays etc.) 8

9 7 Has the mobile plant been modified to cater for the waste industry process i.e. to prevent foreign objects Yes No being trapped and igniting? DESCRIPTION OF WASTE PERMIT INFORMATION 1 Do you hold an Environmental Permit, Waste Management License or Pollution Prevention & Control Permit? Yes No Exempt 2 How many tonnes of waste material per annum are you permitted to process/recycle? 3 Does your waste management license include any inside or outside storage restrictions? Yes No If Yes, please describe ABOUT RECEPTION AND STORAGE OF WASTE MATERIAL INSIDE & OUTSIDE BUILDINGS 1 Do you store Combustible Waste Material and/or unprocessed waste material, including loose, un-compacted and/or Yes No shredded waste material inside buildings, other than current arising s associated with *Same Day Processing? 2 Do you process and/or store any type of refuse derived fuel or solid recovered fuel? Yes No 3 Do you process and/or store any Domestic Municipal Solid Wastes? Yes No If yes to questions 2 & 3 above, please complete the separate **RDF/SRF/MSW questionnaire 4 Please detail your internal waste / stock storage arrangements below (use continuation sheet if required) Location (reception Type of Material Storage Approx Dimension Approx. % of Maximum Tonnage hall, storage shed etc.) stored (loose wastes, arrangement (loose, of each Height x Building floor area stored within baled paper, plastics baled, wrapped Width x Depth used, if externally buildings etc., DMR, RDF, SRF, bales etc.) (metres) stored please state MSW etc.) externally stored a) b) c) d) e) f) 9

10 * SAME-DAY PROCESSING Refers to the amount of material that could be processed during working hours. For example if material processing throughput of X tonnes per hour and is usually operated for Y hours, the maximum amount of material storage would be XY tonnes (X tonnes multiplied by Y hours). ** RDF Refuse Derived Fuel SRF Solid Recovered Fuel MSW Municipal Solid Waste 5 What is to total maximum tonnage of combustible material held on site within buildings 6 What is to total maximum tonnage of combustible material held on site outside buildings 7 What is the maximum length of time combustible waste is kept on site: a) within buildings b) externally 8 What is the maximum weekly tonnage of combustible material being brought on to site? 9 What is the maximum weekly tonnage of combustible material being processed on site? 10 What is the maximum weekly tonnage of combustible material removed from site? 11 Are deliveries of unprocessed waste restricted/prohibited at least 1 hour before the end of normal working hours? Yes No If No, what procedures are in place to detect contaminants / heat sources in the unprocessed after the business is closed for daily operations? 12 Are any road vehicles kept within buildings including workshops overnight/whilst business is closed? Yes No If yes, please detail storage arrangements. 13 Please advise any methods &/or equipment used for monitoring all waste material for possible heat/ignition sources: Please attach all documented procedures to this proposal form. (a) when it enters the premises (b) during the production process (c) during storage 10

11 SUMS TO BE INSURED (PLEASE FULLY COMPLETE) SECTION A - MATERIAL DAMAGE Sum Insured ( ) Sum Insured ( ) Sum Insured ( ) Buildings (Standard Construction) Buildings (Non Standard Construction & Outbuildings Loss of Rent Receivable/Payable Indemnity Period required: In secure Buildings ( ) In the Open ( ) Largest Item ( ) Machinery & Plant General fixtures, fitting & other contents Stock in Trade Stock of Non Ferrous Metal Stock of Fuel/ Diesel/ Oil & Fuel Tanks Computer & Electrical Office Equipment Miscellaneous Items (please define) Note, Machinery, Plant and Stock is insured on an Indemnity Basis please advise if you wish us to consider reinstatement Additional Peril Available Subsidence (Tick if quotation required) Please Note: Subsidence cover is only available if a questionnaire has been completed and accepted by Underwriters. SECTION B - BUSINESS INTERRUPTION 3 Basis of Cover Sum Insured ( ) Indemnity Period Required (Please state the Indemnity Period required) 12 Months 18 Months 24 Months Other Gross Profit: Increase in Cost of Working: Additional Increase in Cost of Working: 11

12 BUSINESS INTERRUPTION - GROSS PROFIT CALCULATOR (Calculation A) - Gross Profit (1) Income / Turnover from Sales & Services: (2) Closing Stock and work in progress at end of the Financial Period* Sub Total 1 (3) Opening Stock and work in progress at beginning of the Financial Period* (4) Uninsured Working Expenses:** Sub Total 2 TOTAL GROSS Profit for Financial Period (Calculation A) (Sub Total 1 minus Sub Total 2) (Calculation B) - Gross Profit Trend (1) GROSS Profit for Financial Period (Calculation A) (2) Add % Trend for Forthcoming Period of Insurance % in s Sub Total 1 (3) Add % Trend for Indemnity Period (See Calculation C) After the Period of Insurance ends % in s Sub Total 2 Total Insurable Gross Profit for Forthcoming insurance (Sub Total 1 plus Sub Total 2) (Calculation C) - Indemnity Period Please indicate the Indemnity Period required (12, 18, 24, 36 Months) Months *To be completed from the Financial Period most nearly concurrent with the most recent insurance year. The amounts of the Opening and Closing Stocks (including work in progress) shall be arrived at in accordance with the Insured s usual accounting methods. These figures should be provided by your Professional Accountant, or in the case of total exemption from audit for small companies, by your nominated official. **Uninsured Working Expenses are those expenses which vary in direct proportion to any variation in the Turnover and which you are therefore able to omit from the insurance cover, for example Purchases (less discounts received), Discounts Allowed, Bad debts, Carriage, Packing & Freight etc... 12

13 Why should I carefully consider my Gross Profit Trend? Profit Trend must be considered when calculating your Gross Profit sum insured. By way of example: If your Indemnity Period is 12 months long and you suffer a serious loss on the 360th day of your annual policy your Gross Profit claim could run on for almost another 12 months after your policy has expired. That is almost 24 months after your original calculation of Gross Profit was made. As a consequence if you have noted a trend toward increased Gross Profit or if at anytime you can foresee ahead the possibility of a sustained period of increased Profit then this should be advised to your insurer. If you fail to notify your insurer prior to you experiencing a serious loss then the policy will not meet a claim for the increased amount of Gross Profit. In addition, if your estimate of Gross Profit is too inadequate then the insurer can apply average and your claim would then be adversely proportionately reduced. Please see below example of a Calculation of Trend. Why should I carefully consider my indemnity period? When considering the length of Indemnity Period your business requires, advice should be sought from appropriate professionals in respect of such matters as the length of time it would take to re-locate to new premises or otherwise rebuild your property. In addition other factors may have a bearing on what you select such as the length of time it would take to replace as new, specialist machinery that may have to be manufactured by 3rd parties. If not already prepared, we would recommend that a disaster recovery plan be drawn up for your business. When completing such a plan you will no doubt visit many challenges that you would face in the event of a serious claim and this will also help you to mitigate your losses. Example Calculation of Trend: NB: When calculating Trend factors inflation should also be taken into account. The Financial Period most concurrent with the forthcoming Period of Insurance: 1,000,000 (Calculation A) Gross Profit Forthcoming Period of Insurance: 1,100,000 1,000, % Gross Profit 1,100,000 Indemnity Period of 12 Months (i.e. Loss on the 360th day of your policy with 12 months to recover) 1,260,000 1,100, % Gross Profit Based upon the above example it can be seen that very easily your Gross Profit calculation could be 260,000 short. When the Insurable Gross Profit is calculated can you please sign to confirm that the figures provided are accurate and you are pleased for Direct Insurance to advise Insurers of these figures and are aware that if the estimate of gross profit is too inadequate the insurer may apply average and any claim would then be adversely proportionately reduced. Signature of Proposer: Print Name: Position Held: Date: Name & Address of Accountants, if applicable: (Please Print): 13

14 HEALTH AND SAFETY 1. Please answer questions a. and b. in relation to this business or any previous business in which the proprietor, partners or directors have traded, in this or any other name: a. Have any insurers in the last five years declined to insure any of you or your businesses, cancelled or refused to renew Yes No any insurance or imposed special terms? b. Have there been any incidents in the last five years where the Health and Safety Executive, Environmental Health Office, Yes No Environment Agency or any other enforcement agency have served any of you with any enforcement measures, prohibition notices or criminal proceedings? Please answer questions c. to f. in relation to the proprietor, partners or directors of this business. Convictions or cautions do not have to be declared if they have become spent under the Rehabilitation of O enders Act Reference to the Rehabilitation of Offenders Act 1974 is a reference to it as it is in force for the time being, taking into account any amendment, extension or re-enactment, and includes any subordinate legislation for the time being in force made under it. 2. Are you, the company or any partner, director or financially associated person involved in any current, ongoing or Yes No potential matters that may give rise to any legal or contractual disputes? c. Have any of you in the last five years been declared bankrupt or insolvent, in connection with this or any other business Yes No in this or any other name, or been disqualified from being a company director or been involved as owner, proprietor, partner or director with any company which went into receivership, administration or liquidation? d. Have any of you in the last six years been the subject of any County Court Judgment and/or been cited in any Yes No unsatisfied court judgments (or the Scottish equivalent) and/or have any court judgments pending? e. Have any of you been convicted or charged (but not yet tried) with any criminal offence other than a motoring conviction? Yes No f. Have any of you committed any offence to which you have admitted and for which you have received an official Yes No police caution? If the answer to any question is Yes please provide full details on the Additional Information sheet at the end of the proposal form. 14

15 CLAIMS & MATERIAL FACTS DECLARATION 4 Give details of all claims and or incidents that may have given rise to a claim in the past 10 years. Incidents that may have given rise to a claim include Fire / Thefts / Malicious Damage whether claimed or not: Incident / Claim Details Date Paid and/or Outstanding Monies 5 For all claims in excess of 25,000, please provide measures taken to avoid further occurrence: Incident / Claim Details Date of loss Measures Taken 15

16 NOTES AND OR ADDITIONAL INFORMATION 16

17 Data Protection Act Provisions Any information provided to the Underwriters will be dealt with in compliance with the provisions of the Data Protection Act For the purpose of providing insurance and handling of any claims which may arise under it, this may necessitate providing certain information which you have provided to other parties. By signing this Questionnaire you agree that such transfer(s) may be made. Choice of Law The Proposer and the Underwriters are entitled to choose the law that will govern this contract of insurance. Unless otherwise agreed the Underwriters propose English Law. Duty of Fair Presentation 1. Before this insurance contract is entered into, the Insured must make a fair presentation of the risk to the Insurer, in accordance with Section 3 of the Insurance Act In summary, the Insured must: a) Disclose to the Insurer every material circumstance which the Insured knows or ought to know. Failing that, the Insured must give the Insurer sufficient information to put a prudent insurer on notice that it needs to make further enquiries in order to reveal material circumstances. A matter or circumstance is material if it would influence the judgement of a prudent insurer as to whether to accept the risk, or the terms of the insurance (including premium). If you are in any doubt as to what constitutes a material fact you should consult your Insurance Advisor. In accordance with section 8 of the Insured Act 2015, failure to disclose a material fact or circumstance could invalidate your contract of insurance or result in a claim being declined or reduce the amount payable in respect of a claim. b) Make the disclosure in clause (1)(a) above in a reasonably clear and accessible way; and c) Ensure that every material representation of fact is substantially correct, and that every material representation of expectation or belief is made in good faith. 2. For the purposes of clause (1)(a) above, the Insured is expected to know the following: a) If the Insured is an individual, what is known to the individual and anybody who is responsible for arranging his or her insurance. b) If the Insured is not an individual, what is known to anybody who is part of the Insured s senior management; or anybody who is responsible for arranging the Insured s insurance. c) Whether the Insured is an individual or not, what should reasonably have been revealed by a reasonable search of information available to the Insured. The information may be held within the Insured s organisation, or by any third party (including but not limited to subsidiaries, affiliates, the broker, or any other person who will be covered under the insurance). If the Insured is insuring subsidiaries, affiliates or other parties, the Insurer expects that the Insured will have included them in its enquiries, and that the Insured will inform the Insurer if it has not done so. The reasonable search may be conducted by making enquiries or by any other means. Declaration I/we declare that to the best of my/our knowledge and belief the information and statements provided herein are true and complete and I/we have made a fair presentation of the risk, by disclosing all material facts or circumstances which I/we know or ought to know or, failing that, by giving the Insurer sufficient information to put a prudent insurer on notice that it needs to make further enquiries in order to reveal material circumstances. I/we undertake to inform the Insurer of any material alteration to those facts occurring before completion of the contract of insurance. I/we declare I/we have read the full terms and conditions of the policy; this includes the wording, clauses and any additional conditions, warranties, subjectivities that have been applied to the policy. I/we agree to adhere to the full terms and conditions of the policy for the duration of the contract. Name of Director/Officer/Board member/senior manager: Signature of Director/Officer/Board member/senior manager: Position Held: For and on behalf of: Date: Please note: Unless dated this Questionnaire will not be valid. Signing this Questionnaire does not bind the Proposer to enter into a contract of insurance. It is agreed that Underwriters are authorised to make investigation and inquiry in connection with this Questionnaire or any Proposal Form that they deem necessary. 17

18 PROPOSER S DETAILS It is a requirement to capture information about every company and subsidiary company that is to be covered by the policy. NOTE only subsidiaries, as defined by the Companies Act, can be insured by a single Employers Liability policy and take a share of that policy s cover. As associated companies do not fall within the subsidiaries de nition they must arrange their own cover to comply with regulations. If you are an individual or partnership, please state your full names including any trading style. 1. Does the business have an ERN exemption? Yes No If No provide ERN If the business is a partnership, LLP, Ltd or PLC please provide full details of all other partners or any subsidiaries on the Additional Information sheet at the end of the proposal form. If you operate from more than one address please list all other business addresses and their business use on the Additional Information sheet. CURRENT INSURANCE ARRANGEMENTS 1. Insurer 2. Broker 3. Premium 4. Renewal date 5. Date commenced trading 6. Is the business VAT registered? Yes No 7. Please give details of any professional or trade associations you are affiliated to 8. Has any part of the current or any historic policy been written on a claims made basis? If so please give details including retroactive dates BUSINESS DETAILS 1. Provide total number of employees/directors (excluding principal/partners) including labour only sub-contractors (maximum at any one time) 18

19 2. Provide total estimated wages in each category for the forthcoming year a. Clerical sta, managerial, directors, sales not engaged in manual work b. Principal/partners own drawings not engaged in manual work c. Principal/partners own drawings if engaged in manual work d. Supervisors wages e. Manual work at insured s own premises i. Pickers and sorters ii. Plant operators f. All other employees/directors inc labour only sub-contractors (please declare by category below) i. ii. iii. g. Manual work away from the insured s own premises i. Plant operators ii. Drivers h. All other employees/directors inc labour only sub-contractors (please declare by category below) i. ii. iii. j. Payments to bona fide sub-contractors 3. Please state the turnover split for the following categories including Landfill Tax Next 12 months Last 12 months Penultimate 12 months a. Civic amenity sites and waste transfer stations b. Waste collection/haulage/transportation/skip hire c. Landfill 19

20 d. All other turnover (please declare by category below) i) ii) iii) e. Please state Landfill Tax Last 12 months Next 12 months 4. Have you or do you anticipate working outside of the UK? Yes No If Yes provide details below 5. Do you require Employers Liability ( 10,000,000)? Yes No 6. Do you require Public/Products Liability? Yes No If Yes state limit of indemnity required 1,000,000 5,000,000 10,000,000 Other Limit 7. Are you presently registered as waste carriers or brokers by the Environmental Agency/SEPA in Scotland/DOENI in Yes No Northern Ireland? If No provide details below 8. Do you hold any form of Waste Management Licence, inc. Mobile Plant Licence issued by the Environment Yes No Agency/SEPA/DOENI? If No or exempt provide details below 9. Please attach a copy of your last Consignee Quarterly Return to the Environment Agency, SEPA or DOENI (if applicable) Attached 20

21 CIVIC AMENITY SITES, WASTE TRANSFER STATIONS, RECYCLING CENTRES AND WASTE PROCESSING PLANTS 1. Hazardous waste (if indemnity is required for hazardous waste as de ned by The Hazardous Waste (England & Wales) Regulations 2005, The Hazardous Waste (Northern Ireland) Regulations 2005 and The Special Waste Amendment (Scotland) Regulations 2004 please specify) a. Asbestos Containing Materials (ACM s) i. Unlicensed asbestos materials (for example asbestos cement/ oor tiles) Yes No ii. Licensed asbestos materials (for example spray and other insulation, AIB and millboards) Yes No If Yes to either of the above, provide details below of storage/handling b. Any other hazardous waste? Yes No If Yes provide details below 2. Is a separate area of your site allocated for each type of waste that you accept? Yes No If Yes explain the separation procedure below 3. Do you transport waste from your site yourselves? Yes No 4. Do you operate as a private company? Yes No 5. Do you have any term contracts with Local Authorities? Yes No If Yes provide details below 21

22 33. Do you allow householders/members of the public access to your site? Yes No If Yes provide details below of how are they supervised (include details of provisions made for this) 34. Do you allow third party waste carriers access to your site? Yes No If Yes provide details below of their activities 35. Are you involved in any type of recycling process on your premises? Yes No If Yes provide details below WASTE CARRIERS HAULAGE TRANSPORTATION AND SKIP HIRE OPERATIONS 1. Do you collect waste from any of the following locations? Domestic premises Yes No Commercial premises Yes No Landfill sites Yes No Incineration sites Yes No Nuclear Yes No Chemical plants Yes No Petro-chemical plants Yes No Offshore sites or docks Yes No Airports/airside Yes No Hospitals/doctors/dentist/vets Yes No Abattoirs Yes No Sewage treatment plants Yes No Mines and quarries Yes No Agricultural sites Yes No If the answer is Yes to any of the above provide details below. Please use the Additional Information sheet if necessary 22

23 2. What types of waste are collected/handled? Green (composting) Yes No Furniture Yes No Bricks/rubble/soil Yes No Food Yes No Metals Yes No ELV s (End of Life Vehicles) Yes No Paper/cardboard Yes No Tyres Yes No Glass Yes No WEEE (Waste Electronic Electrical Equipment) Yes No Plastics Yes No Fridges/freezers Yes No Textiles/shoes Yes No Batteries Yes No Wood/timber Yes No Used engine oil/solvents Yes No Other provide details below: 3. Hazardous waste (if indemnity is required for hazardous waste as defined by The Hazardous Waste (England & Wales) Regulations 2005, The Hazardous Waste (Northern Ireland) Regulations 2005 and The Special Waste Amendment (Scotland) Regulations 2004 please specify below) a. Asbestos Containing Materials (ACM s) i. Unlicensed asbestos materials (for example asbestos cement/floor tiles) Yes No ii. Licensed asbestos materials (for example spray and other insulation, AIB and millboards) Yes No If Yes to either of the above, provide details below of storage/handling 23

24 4. Any other hazardous waste? Yes No If Yes provide details below 5. How many skips do you operate? 6. Are all skips sited on the public highway provided with adequate lights and cones and fluorescent markings? Yes No 7. Are their any occasions where the local authority requires the hirer to provide lights &/or cones for skips on the Yes No public highway? If Yes provide details below 8. Please attach a copy of your skip conditions of hire Attached 9. How many lorries and dustcarts do you operate? 10. Do you use heat away from own premises? Yes No If Yes provide details below LANDFILL SITES (PLEASE COMPLETE THIS SECTION FOR EACH SITE OPERATED/OWNED) 1. Site address 2. Address 1 3. Address 2 4. Town 50. County 51. Postcode 5. Please confirm whether you own or lease the site Own Lease a. If you lease the site do you supply a contractual indemnity to the owner? Yes No If Yes please provide a copy Attached b. What date did you lease the site? 24

25 6. If you own the site please confirm the date that you took ownership 7. When did land filling of the site commence? 8. What was the original capacity of the site? CuM 9. What is the present capacity of the site? CuM 10. What is the estimated annual input to the site? 11. What is the anticipated restoration date? 12. Please provide details below of all types of waste accepted at the site? 13. Please confirm below what method of containment is in operation at the site 14. Please confirm below what methods have been employed to avoid/control leachate breakout and land ll gas migration 15. Please provide details below of site security against fly tipping/trespass 16. Is there a public right of way on the site? Yes No 17. Please attach an OS Map clearly highlighting the site boundary Attached HEALTH AND SAFETY Please specify any accreditations you hold a. Quality Management (e.g. ISO 9000 series) b. Environmental Management (e.g. ISO series) c. Other aspects of your business (e.g. IIP) 2. Do you have a written Health and Safety policy? If Yes please cofirm: Yes No a. The year that it was originally prepared b. The date of the last review 25

26 3. When was your Health and Safety policy last communicated to your employees? 4. Who is responsible for Health and Safety within your company? a. Name of director/employee b. Position within the company c. Formal health and safety training qualifications 5. Do you engage an external organisation for advice/audit of your Health and Safety policy systems? Yes No If Yes provide details below 70. Have you carried out formal risk assessments, documented with relevant Safe Systems of Work? Yes No 71. Do you have a formal plan for review of risk assessments? Yes No 72. Do you have a formal safety-training plan for employees? Yes No 73. Do you have a formal plan for the provision of Personal Protective Equipment (PPE) (as required by the Personal Yes No Protective Equipment at Work Regulations 1992)? 74. Do employees sign for PPE and are records kept? Yes No 75. Have you documented procedures for high risk activities? Yes No 76. Do you operate a formal Permit to Work scheme for high risk activities? Yes No 77. Do you have formal contractor control for visiting contractors? Yes No 78. Do you have a documented fire emergency plan? Yes No 79. Do you have a formal Health and Safety monitoring plan? Yes No 80. Do you have a formal occupational health plan (noise assessments etc.)? Yes No 81. Do you have a formal documented accident investigation plan? Yes No 82. Describe any other Health and Safety activity or any additional comment as necessary 26

27 HEALTH AND SAFETY 1. Please answer questions a. and b. in relation to this business or any previous business in which the proprietor, partners or directors have traded, in this or any other name: a. Have any insurers in the last five years declined to insure any of you or your businesses, cancelled or refused to renew Yes No any insurance or imposed special terms? b. Have there been any incidents in the last five years where the Health and Safety Executive, Environmental Health Office, Yes No Environment Agency or any other enforcement agency have served any of you with any enforcement measures, prohibition notices or criminal proceedings? Please answer questions c. to f. in relation to the proprietor, partners or directors of this business. Convictions or cautions do not have to be declared if they have become spent under the Rehabilitation of O enders Act Reference to the Rehabilitation of Offenders Act 1974 is a reference to it as it is in force for the time being, taking into account any amendment, extension or re-enactment, and includes any subordinate legislation for the time being in force made under it. 2. Are you, the company or any partner, director or financially associated person involved in any current, ongoing or Yes No potential matters that may give rise to any legal or contractual disputes? c. Have any of you in the last five years been declared bankrupt or insolvent, in connection with this or any other business Yes No in this or any other name, or been disqualified from being a company director or been involved as owner, proprietor, partner or director with any company which went into receivership, administration or liquidation? d. Have any of you in the last six years been the subject of any County Court Judgment and/or been cited in any Yes No unsatisfied court judgments (or the Scottish equivalent) and/or have any court judgments pending? e. Have any of you been convicted or charged (but not yet tried) with any criminal offence other than a motoring conviction? Yes No f. Have any of you committed any offence to which you have admitted and for which you have received an official Yes No police caution? If the answer to any question is Yes please provide full details on the Additional Information sheet at the end of the proposal form. CLAIMS HISTORY a. In relation to this business or any previous business in which the proprietor or any partners or directors have traded, in Yes No this or any other name, has there been a claim under any of the cover(s) requested within the last 5 years? b. In relation to this business or any previous business in which the proprietor or any partners or directors have traded, in Yes No this or any other name, have there been any incidents that could have given rise to a claim under any of the cover(s) requested within the last 5 years, for example a small fire If the answer to either question is Yes please provide full details on the Additional Information sheet at the end of the proposal form. 27

28 DECLARATION I/We declare that to the best of my/our knowledge and belief the answers and particulars given on the proposal form are true and complete, and that I/we have not withheld any material information. I/we understand that failure to disclose such information may result in claims not being met. I/We undertake to inform underwriters of any material alteration to these facts occurring before completion of the contract of insurance. A Material Fact is one which an insurer would regard as likely to in uence their assessment and acceptance of this insurance. If you are unsure what to disclose, you should contact your adviser immediately. I/We understand that this proposal form, together with any other information supplied, shall form the basis of the contract of insurance. Signature of Proposer: Print Name: Position Held: Date: 28

29 ADDITIONAL INFORMATION 29

30 Direct Insurance London Market 5th Floor, 35 Great St. Helens, London, EC3A 6HB T: +44 (0) F: +44 (0) E: W: