Salt Lake City Area Office 8722 S. Harrison St. Sandy, UT P.O. Box 4439 Sandy, UT Fax

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Salt Lake City Area Office 8722 S. Harrisn St. Sandy, UT 84070 P.O. Bx 4439 Sandy, UT 84091 800-257-5590 Fax 800-478-9880 Chicag Office 303 W.

1 Salt Lake City Area Office 8722 S. Harrisn St. Sandy, UT P.O. Bx 4439 Sandy, UT Fax Chicag Office 303 W. Madisn Street Suite 2075 Chicag, IL Fax RECYCLING INDUSTRY General Infrmatin Prpsed Effective Date: Applicant s Name: Applicant s Mailing Address: City: State: Zip: Cunty: Business Telephne Number: ( ) Fax: ( ) Physical Lcatin f Business (if different): Ppulatin within 50 miles: Other Lcatins Used: Physical Address: City: State: Zip: Physical Address: City: State: Zip: Please list any ther names the business is r has been knwn by: Cntact Persn: Prducer N.: Prducer s Name: Prducer s Detailed descriptin f business activities (specifically, and by lcatin): Is this a new business? Yes N If n, hw many years have yu been in business? Applicant is: Individual Crpratin Partnership Jint Venture Other (please describe): Annual Payrll: $ Ttal Number f Emplyees: Full-Time: Part-Time: Des yur cmpany have within its staff f emplyees, a psitin whse jb descriptin deals with prduct liability, lss cntrl, safety inspectins, engineering, cnsulting, r ther prfessinal cnsultatin advisry services? Yes N If yes, please tell us: Emplyee Name: Business Telephne N.: ( ) Fax: ( ) Years with Cmpany: Emplyee s Respnsibilities: 1. Insurance Histry Wh is yur current insurance carrier (r yur last if n current prvider)? UDA-A DEC2012 Page 1 f 7

2 Prvide name(s) fr all insurance cmpanies that have prvided Applicant insurance fr the last three years: Cmpany Name Expiratin Date Cverage: Cverage: Cverage: Annual Premium $ $ $ Has the Applicant r any predecessr r related persn r entity ever had a claim? Attach a five year lss/claims histry, including details. (REQUIRED) Yes N Have yu had any incident, event, ccurrence, lss, r Wrngful Act which might give rise t a Claim cvered by this Plicy, prir t the inceptin f this Plicy? Yes N If yes, please explain: Has the Applicant, r anyne n the Applicant s behalf, attempted t place this risk in standard markets? Yes N If the standard markets are declining placement, please explain why: 2. Desired Insurance Cverage t be Quted: General/Cmmercial Liability Prperty Inland Marine Autmbile Limit f Liability - Prfessinal Liability Cverage: Per Act/Aggregate Per Persn/Per Act/Aggregate $50,000/$100,000 $25,000/$50,000/$100,000 $150,000/$300,000 $75,000/$150,000/$300,000 $250,000/$1,000,000 $100,000/$250,000/$1,000,000 $500,000/$1,000,000 $250,000/$500,000/$1,000,000 Other: Other: Self Insured Retentin (SIR): $1,000 (Minimum) $1,500 $2,500 $5,000 $10, Business Activities 1. What percent f grss receipts are frm the sale r prcessing f recyclable materials? % 2. What materials d yu cllect? Metal Flurescent Tubes Plastic Chemical/Liquid Paper Yard Waste Glass Clth/Textiles Aluminum Rubber Other: Other: UDA-A DEC2012 Page 2 f 7

3 3. D yu have a frmal safety prgram? Yes N If yes, please attach a descriptin f the prgram, and answer: a. Wh is respnsible fr safety training? Explain: b. What resurces are cmmitted t safety, safety training, emplyee health and wellness, etc.? c. Attach cpies f attendance lgs fr three recent safety training meetings and indicate the tpics discussed. d. Hw are vilatins f the safety prgram and prcedures handled? Explain: 4. D yu cnduct frmal safety inspectins? Yes N a. If yes, wh is respnsible fr crrecting hazards? Explain: 5. Is there any ff-site wrk (i.e. demlitin, salvage peratins, etc.) Yes N Explain: 6. Des yur peratin currently include a landfill? Yes N a. Has yur peratin previusly included a landfill? Yes N 7. D yu prvide bins, dumpsters, r trailers at custmer sites fr cllectin purpses? Yes N If yes, hw many? 8. D yu have any end prducts sld as used? Yes N If yes, prvide a descriptin f thse prducts, including any warranty: 9. Have yu ever been cited by the EPA? Yes N If yes, prvide details: 10. Any cllectin f: a. cnstructin debris r scrap that cntains asbests r lead paint? Yes N b. batteries, il, antifreeze, fren r tires? Yes N Explain any yes answer: 11. Des yur peratin include ship breaking, battery breaking, PCB transfrmers r handling f radiactive materials? Yes N If yes, explain: 12. Des yur peratin include scrapping autmbiles? Yes N If yes, answer: a. What safety guidelines are in place fr handling gasline and mtr il in the autmbiles? b. What is the prcedure fr handling unspent airbags? c. What envirnmental cntrls are in place t handle leached materials frm engine blcks? Facility Infrmatin 13. Facility is: Gated Lcked Fenced Lighted Has mtin detectrs Guarded If there is an attendant n duty, is the attendant trained in: a. Hazardus waste identificatin? Yes N b. Hazardus waste detectin? Yes N 14. Is facility pen t the public? Yes N If yes, explain: 15. D vendrs, custmers and/r the general public deliver r pick up materials? Yes N a. Are there safety guidelines psted regarding the delivery and pick up f materials? Yes N 16. Is yur facility used by ther recyclers r trash haulers? Yes N a. Is a release f liability frm signed by anyne wh pick up and deliver materials? Yes N 17. Describe recyclable material strage: % Inside % Outside 18. D yu have vacant land? Yes N If yes, explain use: UDA-A DEC2012 Page 3 f 7

4 Autmbile 19. D yu cmply with the U.S. Department f Transprtatin and any state-specific safety standards? Yes N 20. D yu pull MVR s n all drivers? Yes N 21. Are yu required t prvide an ICC filings? Yes N 22. D yu tarp r therwise enclse lse material yu transprt? Yes N 23. D yu have a pst-accident investigatin plicy? Yes N 24. D yu perfrm drug/alchl testing? Yes N 25. Describe vehicle maintenance prgram including frequency f service: 26. Describe prtectin f garage lcatins: 27. What is radius f peratins? Less than 50 miles miles Mre than 200 miles 28. What is average miles per year per vehicle? 29. Are drivers trained in hazardus waste identificatin? Yes N 30. Describe garage lcatins: Metal Recycling If yu checked Metal in questin 2, answer the questins in this sectin. 31. What percent f yur receipts are frm recycling: % Irn/Steel % Chrmium % Cadmium % Lead % Mercury % Nickel % Manganese % Beryllium % Brass % Aluminium % Cpper % Other: 32. D yu have radiatin detectin equipment in place? Yes N a. If yes, is the equipment: fixed hand-held 33. D yu dismantle and/r recycle tanks? Yes N a. If yes, hw are tanks tested fr residual cntents? b. D yu wn r peratin any f the fllwing: Smelting Operatin Incineratr Cgeneratin facility 34. If a smelting peratin exists, what types f metals are being recycled? Steel Brass Irn Cpper Stainless Steel Aluminium Lead Other: 35. Please list the prductin machinery: a. Values: b. Age: c. Cst t replace: d. Size (h.p./tnnage/utput): 36. What is the size f the largest mtr running any equipment? a. D yu have a spare? Yes N 37. What critical spares d yu keep n hand? a. What is the lead time t btain additinal cmpnents? 38. Please attach a descriptin f yur prductin machinery maintenance plicy and prcedures. 39. Is there a preventative maintenance prgram? Yes N a. If yes, please describe: 40. Hw ften are seals and hses n machinery checked? 41. Hw ften are seals and hses n the machinery replaced? 42. What is the experience and training f the persnnel wh service the prcessing equipment? 43. Where and hw are flammables including acetylene tanks stred? 44. Is machinery custm-made r freign-made? 45. Hw many prductin lines are there? a. Is there duplicity in the prductin prcess? Yes N UDA-A DEC2012 Page 4 f 7

5 46. List the number f: a. Wrking days per week: b. Shifts per day: c. Number f emplyees: 47. What is the experience level f the machinery peratrs? 48. Is equipment checked fr ht spts at the end f each day? Yes N a. Is the prductin machinery equipped with heat sensing devices? Yes N 49. Number f incming electric feeds, autmatic switchver: 50. Number f transfrmers: a. Wh wns the transfrmers? Insured Utility b. Age f transfrmers: c. KVA: d. Valve: e. Rewired: 51. Is emergency pwer available? Yes N 52. Are there any welding r cutting peratins? Yes N a. If yes, where? b. If yes, what cntrls are in place t minimize fire ptential? Plastics Recycling If yu checked Plastics in questin 2, answer the questins in this sectin. 53. What types f plastics d yu recycle? Indicate percentage: % Famed % Hllw Plastic (bttles) % Mlded Parts 54. What frm are plastics in? Indicate percentage: % Pellets % Granules % Flakes % Pwders % Slids 55. Indicate hw plastics are stred previus t recycling: a. What is the maximum height plastics are stred t? Feet b. Strage methd: Gaylrd cartns Lse piled Slid piles c. Is strage inside? Yes N 56. If strage is inside: a. Is it in an area prtected by autmatic fire sprinklers? Yes N b. What building features wuld cntain the spread f heat, smke and flame frm a fire? Fire walls Partitin Walls (blck, brick, wd, dry wall, etc.) Metal Walls Open unrestricted area c. Hw much f the flr space is used fr strage f plastics? Feet 57. If plastics are regrund, describe dust and nise cntrls: 58. Hw are regrund plastics stred (i.e. gaylrd cartns)? Rubber Recycling If yu checked Rubber in questin 2, answer the questins in this sectin. 59. What type f rubber prducts are handled, by percentage? % Tires % Husehld Gds % Extrusins % Other: 60. If tires are recycled, hw are they stred? On End Overlapped Inside Outside 61. If strage is inside: a. Hw high is strage? Feet b. Hw many square feet are used fr strage? c. D autmatic sprinklers prtect the area? Yes N d. What building features wuld cntain the spread f heat, smke and flame frm a fire? Fire walls Partitin Walls (blck, brick, wd, dry wall, etc.) Metal Walls Open unrestricted area 62. If strage is utside, hw clse are tires stred t buildings? feet 63. Are rubber prducts regrund? Yes N 64. If rubber is regrund: a. Describe dust cntrl features: UDA-A DEC2012 Page 5 f 7

6 b. Hw is grund material stred? Paper Recycling If yu checked Paper in questin 2, answer the questins in this sectin. 65. Describe the types f paper recycled, i.e. newsprint, magazines, telephne bks, ffice refuse, etc.: 66. What is percentage f paper is stred inside buildings? % Outside buildings? % 67. Fr paper stred utside: a. Is strage: Clsed Open Array b. Hw high is strage? feet c. Hw many square feet are used fr strage? feet d. Are water hses r pressurized fire extinguishers winterized where necessary? Water hses: Yes N Fire extinguishers: Yes N e. Describe hw paper stred utside is secured against vandalism r arsn: 68. Fr inside strage: a. Is there a wet-pip fire sprinkler system? Yes N b. Hw high is strage? Feet c. Hw many square feet are used fr strage? Feet d. What building features wuld cntain the spread f heat, smke and flame frm a fire? Fire walls Partitin Walls (blck, brick, wd, dry wall, etc.) Metal Walls Open unrestricted area e. Are there any smke, heat r similar fire detectin devices installed in inside areas? Yes N f. Are fire detectin devices mnitred by a central r nrmally attended statin? Yes N 69. If paper is shredded and baled, described dust an nise cntrls: 70. Is smking prhibited thrughut the premises? Yes N 71. Are ht wrk permits used fr welding and cutting peratins? Yes N If yes, attach a cpy. 72. Wh is respnsible fr fire watch activity during welding/cutting peratins? 73. Have emplyees been trained in the use f fire-fighting appliances? Yes N 74. Any cllectin r dispsal f sensitive r cnfidential dcuments? Yes N If yes, please attach a cpy f sample cntract, and describe cntrls in place t maintain cnfidentiality. REPRESENTATIONS AND WARRANTIES The Applicant is the party t be named as the "Insured" in any insuring cntract if issued. By signing this Applicatin, the Applicant fr insurance hereby represents and warrants that the infrmatin prvided in the Applicatin, tgether with all supplemental infrmatin and dcuments prvided in cnjunctin with the Applicatin, is true, crrect, inclusive f all relevant and material infrmatin necessary fr the Insurer t accurately and cmpletely assess the Applicatin, and is nt misleading in any way. The Applicant further represents that the Applicant understands and agrees as fllws: (i) the Insurer can and will rely upn the Applicatin and supplemental infrmatin prvided by the Applicant, and any ther relevant infrmatin, t assess the Applicant s request fr insurance cverage and t qute and ptentially bind, price, and prvide cverage; (ii) the Applicatin and all supplemental infrmatin and dcuments prvided in cnjunctin with the Applicatin are warranties that will becme a part f any cverage cntract that may be issued; (iii) the submissin f an Applicatin r the payment f any premium des nt bligate the Insurer t qute, bind, r prvide insurance cverage; and (iv) in the event the Applicant has r des prvide any false, misleading, r incmplete infrmatin in cnjunctin with the Applicatin, any cverage prvided will be deemed vid frm initial issuance. The Applicant hereby authrizes the Insurer and its agents t gather any additinal infrmatin the Insurer deems necessary t prcess the Applicatin fr quting, binding, pricing, and prviding insurance cverage including, but nt limited t, gathering infrmatin frm federal, state, and industry regulatry authrities, insurers, creditrs, custmers, financial institutins, and credit rating agencies. The Insurer has n bligatin t gather any infrmatin nr verify any infrmatin received frm the Applicant r any ther persn r entity. The Applicant expressly authrizes the release f infrmatin regarding the Applicant s lsses, financial infrmatin, r any regulatry cmpliance issues t this Insurer in cnjunctin with cnsideratin f the Applicatin. The Applicant further represents that the Applicant understands and agrees the Insurer may: (i) present a qute with a Sublimit f liability fr certain expsures, (ii) qute certain cverages with certain activities, events, services, r waivers excluded frm the qute, and (iii) ffer several ptinal qutes fr cnsideratin by the Applicant fr insurance cverage. In the event UDA-A DEC2012 Page 6 f 7

7 cverage is ffered, such cverage will nt becme effective until the Insurer s accunting ffice receives the required premium payment. The Applicant agrees that the Insurer and any party frm whm the Insurer may request infrmatin in cnjunctin with the Applicatin may treat the Applicant s facsimile signature n the Applicatin as an riginal signature fr all purpses. The Applicant acknwledges that under any insuring cntract issued, the fllwing prvisins will apply: 1. A single Accident, r the accumulatin f mre than ne Accident during the Plicy Perid, may cause the per Accident Limit and/r the annual aggregate maximum Limit f Liability t be exhausted, at which time the Insured will have n further benefits under the Plicy. 2. The Insured may request the Insurer t reinstate the riginal Limit f Liability fr the remainder f the Plicy perid fr an additinal cverage charge, as may be calculated and ffered by the Insurer. The Insurer is under n bligatin t accept the Insured's request. 3. The Applicant understands and agrees that the Insurer has n bligatin t ntify the Insured f the pssibility that the maximum Limit f Liability may be exhausted by any Accident r cmbinatin f Accidents that may ccur during the Plicy Perid. The Insured must determine if additinal cverage shuld be purchased. The Insurer is expressly nt bligated t make a determinatin abut additinal cverage, nr advise the Insured cncerning additinal cverage. 4. The Insurer is herein released and relieved frm any and all respnsibility t ntify the Insured f the pssible reductin in any applicable Limit f Liability. The Insured herein assumes the sle and individual respnsibility t evaluate, cnsider, and initiate a request fr additinal cverage r reinstatement f the annual aggregate Limit f Liability which may be exhausted by any single Accident r cmbinatin f Accidents during the Plicy Perid. Dated: Applicant: Dated: Agent/Brker: Signature Signature Print Name Print Name UDA-A DEC2012 Page 7 f 7

Salt Lake City Area Office 8722 S. Harrison St. Sandy, UT P.O. Box 4439 Sandy, UT Fax

Salt Lake City Area Office 8722 S. Harrisn St. Sandy, UT 84070 P.O. Bx 4439 Sandy, UT 84091 800-257-5590 Fax 800-478-9880 Chicag Office 303 W. Madisn Street Suite 2075 Chicag, IL 60606 800-456-4576 Fax