RECYCLER S COMPOSITE PACKAGE APPLICATION CGL / PROPERTY / POLLUTION Page 1 of 6

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1 RECYCLER S COMPOSITE PACKAGE APPLICATION CGL / PROPERTY / POLLUTION Page 1 of 6 Name of Applicant: Mailing Address: Location Address: Applicant is: Individual Corporation Partnership Joint Venture Limited Liability Company Website Address: SECTION 1 COMMERCIAL GENERAL LIABILITY 1. FULL DESCRIPTION OF OPERATIONS: 2. How long has applicant been in business? Years experience: 3. Annual gross receipts: No. of Employees: 4. Projected tonnage for all recycling operations : 5. Do you have Commercial Auto coverage on all vehicles? YES NO If yes, limits of liability carried : $ 6. Indicate which of the following materials are collected by the applicant: Aluminum/Copper/Nickel/Scrap Metal/Tin/Iron YES NO Oil collection (used) YES NO Bottles (glass/plastic) YES NO Paper/Cardboard(Bailed) YES NO Batteries/Oil/Antifreeze YES NO Plastics YES NO Chemicals YES NO Power Transformers YES NO Clothing/Textiles/Furniture YES NO Rags YES NO Construction Materials(e.g. drywall) YES NO Rubber recycling YES NO Debris (containing asbestos/lead) YES NO If yes, please complete Rubber Supplemental Application. Electronics(Computers/Monitors/Televisions) YES NO Solvents YES NO Glass YES NO Vehicle fluids YES NO Green Composting YES NO (Specify): Grease collection YES NO Wood pallets YES NO Hospital / medical materials YES NO Lead YES NO Fridge / freezers YES NO Medical Supplies/Other (Please Specify): 7. Does applicant collect any hazardous materials not identified above? YES NO If yes, explain: 8. Does applicant provide bins, dumpsters or trailers at customer sites for collection purposes? YES NO If yes, how many: Subcontracted Operations: 9. Describe any operations subcontracted to others: 10. Are certificates of insurance required from sub-contractors? YES NO 11. Do subcontractors name applicant as an additional insured on their policy? YES NO

2 RECYCLER S COMPOSITE PACKAGE APPLICATION CGL / PROPERTY / POLLUTION Page 2 of 6 Other Operations: 12. Does applicant engage in the following operations? Auto dismantling YES NO Hauling for others YES NO Garbage or refuse haulers YES NO Remanufacturing/refurbishing of products YES NO Iron or steel merchants YES NO Salvage operations YES NO Junk yards or junk dealers YES NO Scrap metal dealers Landfills or dumps YES NO Smelting/foundry operations YES NO 13. Is there any processing of materials beyond pure collection and drop off? YES NO If yes, indicate below: Grinding YES NO Hot Works/Processes (other than YES NO Dismantling YES NO incidental welding/torch cutting) Disassembling/Stripping Chemicals YES NO Other operations: please describe: Material Handling: 14. How is the recycled material received and handled? 15. Employees trained in hazardous waste identification? YES NO 16. Is there a formal response and control program in place for a hazardous substance leak or spill? YES NO 17. What is the procedure if radioactive material is received? Describe the radiation detection equipment used: Number of Employees trained in utilization: 18. Are sorting areas fenced and separated from areas accessible to the public? YES NO 19. Do you have any end products sold as new or used (including e-recycling products)? YES NO a) Do you provide warranties for these products? YES NO b) Describe these products, who sold to, and the end user: REQUIRED CGL COVERAGE LIMITS: GL Limit $ NOA Limit $ SECTION 2 PROPERTY 20. Full Address of property to be insured: 21. Are the premises in a good state of repair and is all plant and machinery in good order? YES NO 22. 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(s): Construction 23. # of Stories: Year Built: Square Footage: 24. Walls - HCB Frame Metal Clad Other: 25. Roof - Concrete Steel Deck Wood Joist Patent Updates - Full Partial Year: Protection 26. Fire Hydrant within Feet Meters Fire hall Fulltime kms Volunteer kms

3 RECYCLER S COMPOSITE PACKAGE APPLICATION CGL / PROPERTY / POLLUTION Page 3 of Is combustible material and/or waste stored outside within 6 meters of any building or outbuilding? YES NO If yes, please give full details: 28. Are flammable liquids or hazardous chemicals used or stored? YES NO If yes, please give full details: 29. Are Smoke Detectors fitted in and/or to the premises? YES NO SECTION 3 POLLUTION LIABILITY AND CLEAN UP FOR PREMISES 30. Covered Locations: (please list all locations) Legal Address Nature of Operations/Occupancies Size at lot (Sq.ft) First Year Occupancy Leased (L) Owned (O) Past uses of this Location (please indicate none if applicable) 31. Are any of the covered locations occupied by any other companies? YES NO If yes, please provide all company names and a description of operations performed by each company: 32. Do any of the Covered Locations have above ground or underground storage tanks? YES NO (If yes, please complete the Storage Tanks Exposures section of this form. 33. Are any of the following exposures located on site or in proximity of any of the proposed insured sites? (please indicate which site by location #): Waterbodies Onsite Neighboring (within 100 m) None Location #: Retail Fuel Outlets Onsite Neighboring (within 1 km) None Location #: Operations considered or relating to tank farm, oil & gas production, petro-chemical manufacturing, landfill or heavy manufacturing Onsite Neighboring (within 1 km) None Location #: MATERIALS HANDLING, WASTE HANDLING AND TRANSPORTATION Raw: Total: Maximum: Method: Name of Waste Hauler: Waste Description: On Site Storage Method (prior to offsite transportation): Length of Storage at On-site: Quantity (per year): Disposal Location (Name/Address): THIRD PARTY EXPOSURES Please describe the properties immediately adjacent to the Covered Locations (please provide answers for each Covered Location):

4 RECYCLER S COMPOSITE PACKAGE APPLICATION CGL / PROPERTY / POLLUTION Page 4 of 6 STORAGE TANK EXPOSURES Please include with this application a copy of a survey plan and blueprint, if available, as well as the Applicant s Spill Prevention, Control and Containment (SPCC) Plan for each facility housing above ground storage tanks. 34. Is there a history of leaks or releases from the tanks at this Covered Location? YES NO 35. Were all tanks new at installation: YES NO If no, please provide details regarding the date manufactured and any upgrades or changes made to the tank since the date manufactured. 36. Have any repairs or upgrades (including relining) been performed within the past 10 years for any tank? YES NO If yes, why were the repairs or upgrade performed? 37. Were any tanks ever removed or closed at any of the listed facilities? YES NO If yes, please provide details why: 38. Do any plans exist to remove or replace any tanks within the next 12 months? YES NO If yes, please provide details of the planned dates and actions: 39. Are there any oil/water separators on any of the listed facilities? YES NO REQUIRED EIL LIMITS: Deductible: EXISTING POLLUTION AND ENVIRONMENTAL INSURANCE COVERAGE Current Environmental Insurance Carrier Period of Coverage (D/M/Y) Type of Coverage (G=Gradual, S&A=Sudden and Accidental) Time on Risk Deductible Premium Period: Retroactive Date: years TANK SCHEDULE 40. Location Address (please complete one schedule for each location): ABOVE GROUND STORAGE TANKS 41. Is there any related underground piping? If yes, please complete piping section below. YES NO TANK # YEAR INST. CAPACITY (litres) (double wall or single wall) MATERIAL CONTENTS REG. COMP.* LEAK DETECTION BASE CONSTRUCTION DIKING CONSTRUCTION OVERFILL PROTECTION PROTECTION FROM VEHICLE IMPACT

5 RECYCLER S COMPOSITE PACKAGE APPLICATION CGL / PROPERTY / POLLUTION Page 5 of 6 NDERGROUND STORAGE TANKS TANK INFORMATION PIPING INFORMATION TANK # YEAR INST. CAPACITY (litres) (double wall or single wall) MATERIAL CONTENTS REG. COMP.* LEAK DETECTION YEAR PIPING INSTALLED PIPING CONSTR (double wall or single wall) PIPING CONSTRUCTION MATERIAL PIPING LEAK DETEC. TANK AND PIPING CONSTRUCTION MATERIAL BASE AND DIKING CONSTRUCTION CONTENTS LEAK DETECTION F = FIBREGLASS R = REG. GASOLINE DW = INTERSTITIAL MONITORING I = IMPERMEABLE (concrete, clay synthetic) E = ETHANOL ATG = AUTOMATIC TANK GAUGING FRB = FIBREGLASS REINFORCED PLASTIC D = DIESEL VW = VAPOUR MONITORING WELLS P = PERMEABLE (dirt, earth, gravel) NO = NEW OIL GW = GROUND WATER MONITORING WELLS FCL = FIBREGLASS CLAD STEEL WO = WASTE OIL SIR = STATISTICAL INVENTORY RECONCILIATION N = NONE K = KEROSENE MTG = MANUAL TANK GAUGING CPS = CATHODICALLY PROTECTED STEEL PCL = POLYETHYLENE CLAD STEEL * REGULATORY COMPLIANCE: DENOTES A TANK MEETING PROVINCIAL, TECHNICAL AND LEAK DETECTION STANDARDS. All storage tanks at a given facility must be identified (whether or not they are owned or operated by the applicant). If Premier is unable to cover all storage tanks at a facility, Premier may not be able to cover any of the storage tanks at t hat facility. LOSS HISOTRY ALL: 42. Indicate all claims or losses that may give rise to claims for the prior five years. Check if no losses last five years Date of Loss Description of Loss Amount Paid Claim Status (Open or Closed) $ $ $ 43. Are any of the Covered Locations contaminated? YES NO 44. Has any insurance Insured denied, cancelled or non-renewed environmental impairment liability coverage to the Applicant? YES NO

6 RECYCLER S COMPOSITE PACKAGE APPLICATION CGL / PROPERTY / POLLUTION Page 6 of 6 REQUIRED PROPERTY COVERAGE LIMITS: Property Coverage Deductible Limit Required Building Contents Equipment Profits Extra Expense Earthquake Flood Coverage INSPECTION /RISK MANAGEMENT OF ALL COVERED LOCATIONS 45. Inspection contact (please provide the name and telephone number of the inspection contact for each Covered Location): 46. During the last five years, has the Applicant or a third party conducted an environmental audit or inspection survey of the Applicant s Covered Locations or operations? If yes, please attach. 47. Are there any statutes, standards, or other city, provincial or federal regulations relating to the protection of the environment which apply to any location with which the Applicant cannot at present comply? YES YES NO NO For purposes of the Insurance Companies Act (Canada), any document would be issued in the course of Lloyd s Underwriters ins urance business in Canada. Where (a) an Applicant for this contract gives false particulars to the prejudice of the insurer or knowingly misrepresents or fails to disclose any fact in any part of this application required to be stated therein; or (b) the insured contravenes a term of the contract or commits a fraud; or (c) the Insured willfully makes a false statement in respect of a claim, a claim will become invalid and the Insured s right of recovery is forfeited. The Applicants have reviewed all parts and attachments of this application and acknowledge that all information is true and correct and understand that this application for insurance is based on the truth and completeness of this information. I have provided personal information in this document and otherwise and I may in the future provide further personal information. Some of this personal information may include, but is not limited to, my credit information and claims history. I authorize my broker or insurance company to collect, use and disclose any of this personal information, subject to the law and my broker s or insurance company s policy regarding personal information, for the purpose of communicating with me, assessing my application for insurance and underwriting my policies, evaluating claims, detecting and preventing fraud, and analyzing business results. I confirm that all individuals whose personal information is contained in this document have authorized that I agree to the above on their behalf. Printed Name: Applicant s Signature: Brokerage: Broker Position Held: Date: Broker Name: Broker phone: Premier Canada Assurance Managers Ltd. is one of Canada s largest Managing Underwriting Agents. The underwriting insurance carrier varies by line of business and region - please refer to specific quote for declaration of the underwriting insurance company(s). ** application and attachments to - newbizcommercial@premiergroup.ca ** Vancouver - T F