Environmental Impairment Liability

Transcription

1 PROPOSAL FORM Environmental Impairment Liability Fixed Facilities, Pipelines & Storage Tanks & Goods in Transit Pollution Liability (road) Underwritten by The Hollard Insurance Co. Ltd, an authorised Financial Services Provider ITOO is an Authorised Financial Services Provider. FSP No

2 1 Please answer ALL questions completely Should any question or part thereof not be applicable, please state N/A Should insufficient space be provided, please continue on your company letterhead Please ensure that you complete this form fully to enable us to provide you with an accurate and speedy quotation. The truth of the statements made in this form and any other documentation you may provide to us will be incorporated within your policy should our terms be accepted. The completion of this form does not bind YOU or US to any contractual arrangement unless you accept our terms for the issuing of an insurance policy. From the date that you sign this proposal any change in risk or any claims or circumstances that may give rise to claims against you at a later date, must be declared to us. This applies whether or not the completion of this proposal is for a new policy or renewal of an existing policy. Existing insurances with us and generally with other Insurers will lapse at midnight on the last day of your expiring policy. Any extensions of cover or requests to hold covered must be received and agreed by this office prior to the expiry of the current policy. Liability policies may be written on a Claims Made basis which means that; a) Indemnity provided is in respect of claims made against you or you becoming aware of circumstances occurring that could lead to claims being made against you during the currency of the policy. b) Policies have a Retroactive Date which excludes claims emanating from work undertaken prior to this date. c) Provided there has been no gap in cover we will allow the Retroactive Date to remain unchanged on any new policy issued by us. New Proposal Renewal 1. Details of Broker Name of Broker Key Contact Person (Name) Address Tel Postcode Country 2. Details of Client (Insured) Full registered name of Insured Previous Trading Names Company Registration and VAT Numbers Describe All Business Activities Key Contact Person (Name) Address Office Tel Postcode Mobile No Country registered No of years in operation

3 2 3. Current insurance Do you currently have Environmental Impairment Liability Insurance Yes No Name of Broker Is your current Policy monthly or annual Name of Insurer Inception Date of current policy Does your primary underlying policy cover Dangerous Goods Yes No Note: Dangerous Goods, or Hazardous Substances, include any substances listed in SANS 10228, SANS 10265, SANS (parts 1 3) or regulated by the National Road Traffic Act, Act 93 of 1996, National Railway Safety Regulator Act 16 of 2002 or the Hazardous Substances Act, Act 15 of Previous Insurance Within the past five (5) years has the proposer purchased this type of insurance coverage Yes No If YES, please provide information regarding any such coverage and all available loss information. 5. Claims Within the past five (5) years have any claims been made or legal actions (including any regulatory proceedings) been brought against the proposer or other party to the proposed insurance with respect to a pollution incident Yes No Does the proposer or other party to the proposed insurance have knowledge of any pollution conditions 1 at the proposed covered location Yes No If YES, to the Claims questions above, please provide in a covering letter a brief description of the claim or circumstance (indicate the alleged incident, location, date, type of injury, damage, etc.). Also, please provide a summary of any steps that may have been taken to avoid or mitigate the possibility of a similar loss occurring in the future. 1. Pollution condition is defined as new or pre-existing discharge, dispersal, release or escape of any solid, liquid, gaseous or thermal irritant or contaminant, including, but not limited to, smoke, vapours, soot, fumes, acids, alkalis, toxic chemicals, medical waste and waste materials into or upon land, or any structure on land, the atmosphere or any watercourse or body of water, including groundwater, provided such conditions are not naturally present in the environment in the amounts or concentrations discovered. Pollution Conditions shall not include Microbial Matter.

4 3 6. Schedule of sites included in this proposal Site No. Name of site Description of activities on Site No of years the Site has been occupied/ operational (including previous owners or users) Previous activities on site Types of premises around site or along pipeline (residential, commercial, industrial, farms, etc.) Size (m2 or Ha) Is site owned or leased Site No. Name of site Description of activities on Site No of years the Site has been occupied/ operational (including previous owners or users) Previous activities on site Types of premises around site or along pipeline (residential, commercial, industrial, farms, etc.) Size (m2 or Ha) Is site owned or leased Site No. Name of site Description of activities on Site No of years the Site has been occupied/ operational (including previous owners or users) Previous activities on site Types of premises around site or along pipeline (residential, commercial, industrial, farms, etc.) Size (m2 or Ha) Is site owned or leased

5 4 Site No. Name of site Description of activities on Site No of years the Site has been occupied/ operational (including previous owners or users) Previous activities on site Types of premises around site or along pipeline (residential, commercial, industrial, farms, etc.) Size (m2 or Ha) Is site owned or leased Site No. Name of site Description of activities on Site No of years the Site has been occupied/ operational (including previous owners or users) Previous activities on site Types of premises around site or along pipeline (residential, commercial, industrial, farms, etc.) Size (m2 or Ha) Is site owned or leased Site No. Name of site Description of activities on Site No of years the Site has been occupied/ operational (including previous owners or users) Previous activities on site Types of premises around site or along pipeline (residential, commercial, industrial, farms, etc.) Size (m2 or Ha) Is site owned or leased

6 5 7. Schedule of pipelines included in this proposal Pipe No. Name of site/line Description of contents Age of Pipeline Diameter Pressure Average depth Length (km) Types of premises around site or along pipeline (residential, commercial, industrial, farms, etc.) Does it run in a servitude or on private property Pipe No. Name of site/line Description of contents Age of Pipeline Diameter Pressure Average depth Length (km) Types of premises around site or along pipeline (residential, commercial, industrial, farms, etc.) Does it run in a servitude or on private property Pipe No. Name of site/line Description of contents Age of Pipeline Diameter Pressure Average depth Length (km) Types of premises around site or along pipeline (residential, commercial, industrial, farms, etc.) Does it run in a servitude or on private property

7 6 Pipe No. Name of site/line Description of contents Age of Pipeline Diameter Pressure Average depth Length (km) Types of premises around site or along pipeline (residential, commercial, industrial, farms, etc.) Does it run in a servitude or on private property Pipe No. Name of site/line Description of contents Age of Pipeline Diameter Pressure Average depth Length (km) Types of premises around site or along pipeline (residential, commercial, industrial, farms, etc.) Does it run in a servitude or on private property Pipe No. Name of site/line Description of contents Age of Pipeline Diameter Pressure Average depth Length (km) Types of premises around site or along pipeline (residential, commercial, industrial, farms, etc.) Does it run in a servitude or on private property

8 7 8. Underground Storage tank schedule. Please complete the following schedule in respect of all underground storage tanks at the proposed Covered Locations. Tank No Site at which tank is located Capacity Contents Age Tank Design (single / double skinned) Type of Leak Detection System (Complete from list below) Tank No Site at which tank is located Capacity Contents Age Tank Design (single / double skinned) Type of Leak Detection System (Complete from list below) Tank No Site at which tank is located Capacity Contents Age Tank Design (single / double skinned) Type of Leak Detection System (Complete from list below) Tank No Site at which tank is located Capacity Contents Age Tank Design (single / double skinned) Type of Leak Detection System (Complete from list below) Tank No Site at which tank is located Capacity Contents Age Tank Design (single / double skinned) Type of Leak Detection System (Complete from list below)

9 8 9. Other Information Please indicate which of the following information is available regarding the sites to be insured: Environmental Management System aspects register and operation control procedures Monitoring equipment Environmental Monitoring Data External audit reports and site inspection reports Site plans, Process Flow Diagrams or engineering drawings Permits or licenses Closure plans and financial provisions calculations for closure Layout map indicating size of servitudes Incident report for each site Complaints registers for each site Emergency response procedures Company Organogram Maintenance programs Calibration certificates of monitoring equipment Certification of external laboratories Groundwater or surface water models EIA reports or EMP s CV s of staff responsible for environmental management Leak detection and warning procedures Material safety data Groundwater or surface water models Stakeholder engagement procedures Site security management and access plans If YES to any of the answers above, please indicate where and how we can obtain this information or alternatively attach copies: Limits of Liability and Excess for Quotation Purposes Required inception date of Environmental Policy Do you require automatic re-instatement Yes No

10 9 10. Environmental Limits and Excess Required for Fixed Facilities Requested Limits of Liability for Fixed Facilities (i.e. Sites) (please complete Limit of Liability either per site or per claim) Limit of Liability per site per annum Limit of Liability per claim per claim Excess Annual Aggregate (ZAR) 11. Environmental Limits and Excess Required for Pipelines Requested Limits of Liability for Pipelines Limit of Liability per claim per annum Excess Annual Aggregate (ZAR)

11 Environmental Limits and Excess Required for UST s Requested Limits of Liability for Underground Storage Tanks (please complete Limit of Liability either per site or per claim if not included in Section 10 above) Limit of Liability per site per annum Limit of Liability per claim per claim Excess Annual Aggregate (ZAR) Do you require cover for fuel spills for vehicles not carrying Dangerous Goods Yes No Please state territorial limits required for GIT environmental cover (please note all cover is available throughout Sub-Saharan Africa please specify for which countries you require cover) and percentage of Annual Carry to each Country: 13. Details of Fleet & Operations Requested Limits of Liability for Quotation Purposes Limits per vehicle carrying Dangerous Goods (ZAR) Limits per Vehicle not carrying Dangerous Goods (ZAR) Excess options (ZAR) Annual Aggregate (ZAR) Note: vehicles include trucks, horses, trailers, tankers, wagons, etc. for road transport.

12 11 No of vehicles requiring Environmental Pollution Cover No of vehicles used to transport Dangerous Goods Is transport only conducted in South Africa Are you planning on increasing services outside of SA in the next year Total No of vehicles in current fleet No of trips per month per vehicle carrying dangerous goods % of total distance driven per annum outside of SA Are you transporting or planning to transport Dangerous Goods outside of SA Which other countries are currently being serviced or planning to be serviced Main routes covered inside and outside of SA NB: PLEASE ATTACH A FLEET LISTING 14. Driver details Do all drivers have valid driver s licences applicable to vehicles driven Yes No Do all drivers have valid Professional Driving Permits allowing them to transport dangerous goods Yes No 15. Details of driver training programme Who performs the driving training programme Contact details of trainer When was this training last done How often is the training done 16. Risk Information Are your vehicles fitted with a tracking unit Please provide details Does it have 24 hr monitoring Please provide name of Service Provider Do your drivers travel at night Where do they stop How often do they stop Do you have co-drivers in each vehicle Short Haul % Long haul % Max distance travelled per trip Do you do route planning Have any risk assessments been performed on your operations in the last 24 months Yes No Please state by whom

13 Details of vehicle maintenance program 18. Details of emergency response spill plan 19. Details of accident investigation plan 20. How is Cargo transported (Please tick which is used) Bulk Raw material Containerized Drums Tankers Other please describe 21. Commodities Transported Approx. volume transported per month Approx. no of trips per month Approx. volume transported per month Approx. no of trips per month Dairy Products Gas Cement Chemicals Solvents Liquor Nonflammables Flammables Paint Radioactive Asbestos Explosives Poisonous chemicals Oil Petroleum Diesel Other Other

14 13 Average volume of on-board fuel carried in tanks (across all vehicles in fleet) Any other substances transported which are listed in SANS Approx. volume transported per month Approx. number of trips per month Please add if required 22. Previous Insurance Within the past five (5) years has the proposer purchased this type of insurance coverage Yes No If YES, please provide information regarding any such coverage and all available loss information.

15 Claims Within the past five (5) years have any claims been made or legal actions (including any regulatory proceedings) been brought against the proposer or other party to the proposed insurance with respect to a goods in transit incident Yes No If YES, please provide information regarding all available claims information below: Date of Incident Location of Incident Value of Claim (ZAR) Substance Spilt Volume Spilt Name of Clean-Up Contractor used IMPORTANT: Please note that the quote and cover to be provided will be subject to drivers having the appropriate licence, and adherence to legislation regarding the transportation of Dangerous Goods. DECLARATION I/We the undersigned do hereby declare and state as follows that: The information contained in this application form is true and correct and that I/we have not miss-stated or suppressed any material fact. I/We have obtained the express consent to the disclosure and use of sensitive personal data from every subject whose sensitive personal data is supplied in connection with this proposal for the purposes of (a) underwriting the risks and (b) performing any resulting insurance contract. I/we understand that the information contained herein will be used for the assessment of my/our risk and together with any other material information supplied by me/us shall form the basis of any contract of insurance effected thereon. I/we undertake to inform underwriters of any material alteration to these facts occurring before the completion of the contract. Signature of proposer or person signing on behalf of the proposer Full name Position held D D M M Y Y Y Y Date