Sanitation and Waste Management Insurance Form
Business Information
Business Name (Legal Entity)
*
Address
*
FEIN
*
DOT #
*
MC Docket #
*
Annual Revenue
*
Annual Payroll
*
Number of Trucks
*
Number of Trailers
*
Hauling
Type of Collection
Residential %
*
Commercial %
*
Construction %
*
Industrial %
*
Medical %
*
Septage %
*
Used Oil %
*
Asbestos %
*
Other Hazardous or Special Waste %
*
Is equipment maintained on a regular schedule?
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Yes
No
Do you provide the maintenance for your trucks?
*
Yes
No
Where are your trucks stored?
*
Is there security at the storage site?
*
Yes
No
If so, what type? (Fenced, security, personnel, etc.)
Landfills
Do you own or operate a landfill?
*
Yes
No
What type of landfill do you own / operate?
*
Hazardous
Non-Hazardous
N/A
What type of waste are accepted?
Municipal Solid Waste %
*
Demolition and Construction Waste %
*
Special or Residual Industrial Waste %
*
Wastewater Treatment Sludges %
*
Incinerator Ash Residue %
*
Asbestos %
*
Medical / Infectious Waste %
*
Other Waste %
*
Please describe other if applies
What is the average currently permitted for your waste disposal in acres?
*
Year when landfilling began
*
How much waste is accepted per day in tons?
*
What were the total revenues received for waste disposal for the most recent fiscal or calendar year? $
*
Is the area fenced?
*
Yes
No
Do you accept waste from the general public in small vehicles?
*
Yes
No
If yes to question 8, do you provide a separate unloading area away from large commercial trucks that use the site?
Yes
No
Do you currently have Environmental Impairment Liability Insurance?
*
Yes
No
Hazardous / Medical Waste Operations
Please Indicate the area(s) listed below in which your company provides services by listing the approximate percentage of your company's operations:
Consulting Services %
*
Cleaning Pipes / Tanks or Sites
*
Closures - UST's / AST's %
*
Handling Bulk or Contained Liquids %
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Handling Bulk or Contained Solids %
*
Recycling / Reclamation %
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Site Cleanup / Restoration %
*
Spill Cleanup / Restoration %
*
Thermal Destruction %
*
Kilns / Incinerators / Furnaces %
*
Treatment - Biological / Chemical %
*
Treatment Autoclave / Microwave %
*
Radioactive Waste %
*
Transfer Station Operations
Number of Acres of land involved in your current operations in acres
*
Do you accept waste from the general public in small vehicles?
*
Yes
No
If yes to question #2, do you provide a separate unloading area away from large commercial trucks that use the facility?
Yes
No
What were the total revenues received from transfer operations for the most recent fiscal or calendar year? $
*
Recycling Operations
Do you recycle materials other than glass, metal, plastics, paper or wood?
*
Yes
No
What were the total revenue received from recycling operations for the most recent fiscal year or calendar year? $
Thank you for filling out the form! We will get back to your shortly with a quote.
Please be prepared to provide the following - Current Policies or Certificate of Insurance, 5 Year Loss Runs, Revenue and Payroll Information (3 Prior Years) and Copies of Maintenance and Safety Programs.
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