Waste Operations - Primary Supplemental Application

Transcription

1 Waste Operations - Primary Supplemental Application APPLICANT INFORMATION Business Name: Doing Business As: Mailing Address: Garaging Location: (If Different from Mailing Address) Phone number: Website Address: Subsidiaries & Affiliates: Other Named Insureds (use separate sheet of paper if necessary): Additional Named Insured Relationship to First Named Insured in Business: years First year under current management (YYYY): of experience in waste management: years If there have been any operational changes in past five years, please describe: Have you operated under any other name in the past 5 years? Under what name and at what address did you operate? If : Describe the circumstances that lead to the name change. Do you own/operate a recycling collection center, transfer station, material recovery facility or landfill? (If, please include supplemental application.) Key Management Personnel (include telephone #'s & extensions if different than above) President: Operations Mgr: Main Contact's Address for Claims: WST Loss Control: Accounts Payable: Page 1

2 Other Key Information Business Type (Check 1): Operating Authority: Corporation LLC Common Carrier Partnership Municipality Contract Carrier Proprietorship Other Private Carrier OPERATIONS - Attach additional sheets as necessary Key Identification Numbers: FEIN: MC Docket: U.S. DOT: RCRA Site ID: ##### ##### Describe all operations conducted by the applicant (be specific): Are you involved in any operations not related to waste? If, please complete below. Please include a National Interstate Miscellaneous Operations Supplemental Application, if applicable. Percent of Total Description of n-waste Operations Address Operations Type of Hauling based on percent of Gross Receipts Type of Operation Residential Collection Commercial Collection Industrial Waste Liquid Waste Construction & Demolition Debris Transfer Station to Landfill Other (please describe) Total Estimated Pct. of Gross Receipts Do you haul hazardous waste? If yes, what is being hauled? Do you have asume the liability of others in contracts, such as with a municipality? If, please explain: If you haul interstate, list all states of operation. For Solid Waste operations, is waste transported directly to a landfill? If, is waste transported directly to transfer station/incinerator? Do not haul interstate WST Page 2

3 Transfer Station Location(s): Landfill Location(s) : Average Distance from Garaging Location to Transfer Station or Landfill: If any employees are permitted to take vehicles home at night, is there a written company policy regarding use of the vehicles by others? Miles t permitted OPERATIONAL TERRITORY Radius - What amount of your operations fall within the following - indicate as a percent: 0-50 Miles Miles > 200 Miles Urban: Suburban: Rural: What percent of your drivers follow the same daily route? Are any routes on non-paved roads or off-road? If yes, please explain: What is the average distance of route? What is the distance of the longest route? miles miles Percentage of Routes: 1 Person: 2 People: More than 2: Operations supervision includes: Recording Devices Radio Dispatch GPS Devices Cell Phones DRIVER INFORMATION Number of drivers: Total driver compensation Total. of Employees: Upcoming policy Previous policy 2nd previous 3rd previous In the past year, how many drivers were: Hired Terminated Suspended Min. Experience/Age Information Percent of Drivers Who Are: Pct. of Drivers: Miles Hourly: Union: Driver Age Salaried: n-union: Weight: Trips: Does the applicant maintain driver files in full compliance with DOT regulations? What percent of the drivers are compensated on a "day rate" or "daily rate" basis? What percent of routes are subject to route supervision? Number of route supervisors: Total number of routes: WST Page 3

4 Driver selection procedures include the use of: (Check all that apply) Written Application MVR Check Interview Drug Test Written Test Pre-Hire Physical Reference Checks Road Test Does your new driver hire orientation include? (Check all that apply) Familiarization with equipment Familiarization with company rules Ride along with experienced driver Familiarization with routes Training in handling comm Procedures for accident reporting Who administers driver hiring? Title: What is the minimum required number of years of U.S. driving experience? Who administers driver training? Title: Length of training program: Is training mandatory? Owner/Operator Information: Do you utilize Owner/Operators? Minimum auto liability limits required of owner/operators: If, how many? $ Are certificates of insurance kept on file as evidence of the owner/operator's limits of liability? Is the owner/operator required to name you as an additional insured? years MAINTENANCE PROGRAM Is there a written maintenance program? Total number of mechanics? Name of Maintenance Mgr: Yrs w/co. Yrs. In Maint. Maintenance program is provided for: Vehicle Maintenance is: Which of the following do you have? Pre and post trip inspections are made: How often are vehicles serviced? Specifically, how often are brakes serviced? How long are maintenance records retained? What is your vehicle replacement policy? Describe your tire replacement policy: Describe if and when retreads are used: Company Vehicles Vehicles O Internal External (body) Both Parts department Body shop Service bays Controlled inspection reports Every Every trip trip Daily Daily Other Other Daily Daily Weekly Weekly Monthly Monthly As As Needed Needed If you do not have your own maintenance/repair facility, please describe the maintenance program: What type of fuel is used? Is a refueling station onsite? WST Diesel Diesel CNG CNG LPG LPG Electric Electric Unleaded Unleaded Gas Gas Other: Other: If you have underground storage tanks, please provide the following UST insurance policy information: Policy #: Insurance Co: Effective Date: If you have above ground storage tanks, please provide the following: Number of tanks: Does the total capacity of all AST's that are greater than 55 gallons exceed 1,320 gallons? If, provide copy of Spill Prevention Control and Countermeasure (SPCC) plan. Page 4

5 Aboveground Storage Tank Info (cont'd) Are AST's guarded by concrete-filled protective posts? Is there secondary containment? Construction material: Is the capacity of secondary containment at least equal to a 25-year, 24-hour rainfall? VEHICLE INFORMATION Number of Vehicles Used: Number of Each Vehicle Type Equipped With: Please complete the unshaded boxes in the chart. Total Number of Vehicles by Type Regular use - Three or More Days/Week Less Than Three Days Per Week Spare - Less Than 10 Times a Year Backup Alarms Baffles Battery Disconnect Engine Monitoring Eyewash Solution Fender Spot Mirrors Fire Extinguishers GPS Rearview Camera Average Value of Vehicle Type Total Value of Vehicle Type Front Loader Rear Loader / Packer Side Loader Roll Off/Lugger/Hooklift Bin Trucks Recycle Truck Transfer Truck Mini-Packer Scout or Pal Street Sweeper Tank or Vacuum Truck Truck Tractor Flatbed Truck Trailer - Dump Trailer - Flatbed Trailer - Tipping Trailer - Walking Floor Mobile Document Shredder Pickup - Service Private Passenger Other: Totals: WST Page 5

6 SAFETY - Please attach copy of written safety program Name of Safety Director: Safety Director Phone: Describe the Safety Director's duties: Describe any safety initiatives in place: Describe any safety award program: How often are safety meetings held? Yrs. w/co: in safety: Percent of time spent on safety: Are they mandatory? Describe or attach documentation regarding your program for dealing with drivers who have moving violations or accidents. Does the applicant maintain an accident register & conduct periodic accident analysis? What is your policy regarding driver use of mobile communication devices such as cell phones? Which of the following are included in driver files? (Check all that apply) Application Road Test Results Interview Results Reference Checks MVR Disciplinary Warnings Copy of License Accident Reviews Written Test Results Training Records Background Check Physical Exam Results Are driver files updated annually with information including new MVRs? How often are drivers reviewed? Who holds driver reviews? Are there any current drivers w/ citations for DWI, DUI, or reckless operation? What disciplinary action is taken when drivers develop unacceptable records? PHYSICAL DAMAGE SECTION Comprehensive Deductible: Business Locations Collision Deductible: Loc. #1 Location Address Use or Occupancy of Location Fenced? Guarded? Public Access? Lighted? Owned/ Leased? #2 #3 #4 Does applicant work on miscellaneous equipment not owned by the company? Does applicant lease property or mobile equipment to others? Does applicant sell any product either wholesale or retail? WST Page 6

7 Has the applicant ever been named as a Potentially Responsible Party (PRP) or otherwise been cited for illegal or unlawful dumping of waste? Check any operations listed to the right that are a part of your operation. If any are checked, please complete the applicable National Interstate Supplemental Application. Incinerator Landfill Material Recover Facility Waste to Energy Recycling Center Other Transfer Station INSURANCE QUESTIONS CURRENT INSURANCE Auto Liability Auto Physical Damage General Liability Excess Liability UM/UIM Limits Private Pass Light/Service Heavy/X Heavy PREMIUM CARRIER $ $ $ $ $ $ $ $ Per Person $ Accident $ Per Person $ Accident $ Per Person $ Accident $ LIMITS Requested Policy Term: Is the submitting agent the incumbent agent? to: Date Quote Needed: If, for how many years? yrs. HISTORICAL INFORMATION Projected 12 months Expiring Policy Year 1st Prior Year 2nd Prior Year 3rd Prior Year 4th Prior Year Payroll - Drivers Payroll - n-drivers Total Payroll Number of Power Units Has your insurance been cancelled or non-renewed in the last 5 years for non payment of premium or loss history? (not applicable in MO ) Has the applicant's operating authority ever been suspended or revoked? Do you ever haul noxious, caustic, toxic, flammable or explosive commodities? Have you filed for bankruptcy in the last 5 years? If the answer is "yes" to any of the above four questions, please provide a detailed explanation: Do you purchase an environmental liability policy? If, please answer the following: Who is the environmental liability insurance company? WST Page 7

8 A copy of the Declarations page and schedule(s) of included endorsements from any policy that provides environmental liability coverage for your site(s) or operation(s) must be submitted with this application. Providing this information is not to be considered an application for such coverage from National Interstate Isurance Company. Please read the following carefully and sign below. ALABAMA ARKANSAS APPLICANT'S STATEMENT FRAUD WARNING STATEMENTS Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or who knowingly presents false information in an application for insurance is guilty of a crime and may be subject to restitution, fines or confinement in prison, or any combination thereof. Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison. COLORADO It is unlawful to knowingly provide false, incomplete, or misleading facts or information to an insurance company for the purpose of defrauding or attempting to defraud the company. Penalties may include imprisonment, fines, denial of insurance and civil damages. Any insurance company or agent of an insurance company who knowingly provides false, incomplete, or misleading facts or information to a policyholder or claimant for the purpose of defrauding or attempting to defraud the policyholder or claiming with regard to a settlement or award payable for insurance proceeds shall be reported to the Colorado Division of Insurance within the Department of Regulatory Agencies. DISTRICT OF COLUMBIA WARNING: It is a crime to provide false or misleading information to an insurer for the purpose of defrauding the insurer or any other person. Penalties include imprisonment and/or fines. In addition, an insurer may deny insurance benefits if false information materially related to a claim was provided by the applicant. FLORIDA Any person who knowingly and with intent to injure, defraud, or deceive any insurance company files a statement of claim containing any false, incomplete, or misleading information is guilty of a felony of the third degree. KENTUCKY Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance containing any materially false information or conceals, for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act, which is a crime. LOUISIANA Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison. WST Page 8

9 MAINE It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the purpose of defrauding the company. Penalties may include imprisonment, fines, or denial of insurance benefits. MARYLAND Any person who knowingly or willfully presents a false or fraudulent claim for payment of a loss or benefit or who knowingly or willfully presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison. NEW JERSEY Any person who includes any false or misleading information on an application for an insurance policy is subject to criminal and civil penalties. NEW YORK Any person who knowingly and with intent to defraud any insurance company or other person files an application for commercial insurance or a statement of claim for any commercial or personal insurance benefits containing any materially false information, or conceals for the purpose of misleading, information concerning any fact material thereto, and any person who, in connection with such application or claim, knowingly makes or knowingly assists, abets, solicits or conspires with another to make a false report of the theft, destruction, damage or conversion of any motor vehicle to a law enforcement agency, the department of motor vehicles or an insurance company commits a fraudulent insurance act, which is a crime, and shall also be subject to a civil penalty not exceed five thousand dollars and the value of the subject motor vehicle or stated claim for each violation. NEW MEXICO Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be subject to civil fines and criminal penalties. OHIO Any person who, with intent to defraud or knowing that he is facilitating a fraud against an insurer, submits an application or files a claim containing a false or deceptive statement is guilty of insurance fraud. OKLAHOMA WARNING: Any person who knowingly, and with intent to injure, defraud or deceive any insurer, makes any claim for the proceeds of an insurance policy containing any false, incomplete or misleading information is guilty of a felony. PENNSYLVANIA Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information or conceals for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act, which is a crime and subjects such person to criminal and civil penalties. RHODE ISLAND Any person who knowingly presents false or fraudulent claim for payment of a loss or benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison. WST Page 9

10 TENNESSEE It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the purpose of defrauding the company. Penalties include imprisonment, fines and denial of insurance benefits. VIRGINIA It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the purpose of defrauding the company. Penalties include imprisonment, fines and denial of insurance benefits. WASHINGTON It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the purpose of defrauding the company. Penalties include imprisonment, fines and denial of insurance benefits. WEST VIRGINIA Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison. ALL OTHER STATES Any person who knowingly and with intent to defraud any insurance company or other person, files an application of insurance containing any false information, or conceals for the purpose of misleading, information concerning any material fact thereto, commits a fraudulent act which is a crime. The undersigned applicant (Applicant) hereby applies for a policy of insurance as set forth in the application on the basis of information and statements contained in the application, all supporting and supplementary documents, and this Applicants Statement. The supporting and supplementary documents and this Applicants Statement are incorporated into and a part of the application. The application, all supporting and supplementary documents, and this Applicants Statement shall be referred to below as the Application Materials. If a policy is issued, the Application Materials shall be deemed to be attached to and part of the policy. Applicant understands and acknowledges the following: That insurers receipt and consideration of the Application Materials does not obligate insurer to provide a quotation for insurance to applicant. That any quotations provided will be issued subject to underwriting approval, and will not constitute an offer by the insurer to insure at the quoted rates or prices unless and until such approval has been issued. That coverage can be bound only by insurers authorized representative. That if the initial premium is paid with a check, the coverage provided by the policy is conditioned upon the check being honored when presented for payment, and that if the check is not honored, the policy shall be deemed void from inception due to a lack of consideration. WST Page 10

11 Applicant declares that it has carefully reviewed the information and statements made in the Application Materials and that such information and statements are true and correct. Applicant agrees that any policy of insurance that may be issued now or in the future will be issued in reliance on the information, statements, warranties, and representations contained therein, and that the policy and renewals thereof may be declared null and void by insurer if the Application Materials, or future statements or documents provided by or on behalf of Applicant, contain information that is incomplete, false, or misleading. If Applicant applies for a commercial auto policy that is not rated based on mileage, payroll, or other measure of exposure, Applicant warrants and represents that all vehicles owned by, leased to, or used by the Applicant have been disclosed in the Application Materials or otherwise disclosed in writing to insurer, regardless of whether Applicant intends to schedule such vehicles on the policy issued by insurer. If Applicant applies for a commercial auto policy that is exposure rated, Applicant warrants and represents that all mileage, payroll, or other measure of exposure relating to Applicants operations have been disclosed in the Application Materials or otherwise disclosed in writing to insurer for all applicable periods of time. Applicant understands that an inquiry may be made that will provide applicable information concerning general reputation, financial stability and other pertinent financial data, credit history, driving experience, vehicle usage, and other information considered by insurer in deciding to issue a policy, in determining the rates therefore, and in adjusting claims. Applicant authorizes insurer to obtain such reports in connection with this policy and all renewals thereof. Upon written request, Applicant will be informed of the source of any reports considered by the insurer. Applicant Signature of Officer/Manager or Named Insured Producer Signature Full Name & Title Full Name Company Company Date Date WST Page 11