Information Questionnaire

Please complete and return questionnaire as soon as possible via fax or e-mail

Fax # (760) 918-4068 or / attn: HRT Management

All Clients / CLIENT INFORMATION
Company Name: / Client ID:
Address:
Type of Business: / Today’s Date:
CONTACT INFORMATION
Primary Contact Name: / Primary Contact’s Title:
Office Phone Number: / Cell Phone Number:
Additional Phone Number: / Fax Number:
Email Address: / 1-800- Number:
2nd Contact Name: / Contact Title:
Office Phone Number: / Cell Phone Number:
Additional Phone Number: / Fax Number:
Email Address: / 1-800- Number:
3rd Contact Name: / Contact’s Title:
Office Phone Number: / Cell Phone Number:
Additional Phone Number: / Fax Number:
Email Address: / 1-800- Number:
Please indicate under what circumstances you would like Verisk 3E to notify your Primary Contact.
(e.g. If you have a corporate office and/or contact that needs to be notified of all spills):
/ If a death or severe injury occurs:
/ If any agency representative (county, state, federal) is on-site:
/ If an evacuation of the facility is necessary:
/ If notification to a federal, state, or local agency is required:
/ Bomb Threat:
Other/Comments:
NOTE: In all other situations, 3E is granted the Power of Authority and need not notify the corporate office before initiating spill response. Disregard this section if specific arrangements were determined.
Call Forwarding Information
List forwarding information for non-program related inquiries
All Clients / Call Type / Contact (If Applicable) / Contact Title / Phone Number / E-Mail Address
General Inquiry
Commercial Questions
Technical Advice
Other
Special Instructions (Attach additional pages as needed)
CHEMICAL INFORMATION
What are the most dangerous materials you hold, carry or ship?
List the most dangerous chemicals currently onsite and approximate amount
1.Product Name: / 4. Product Name:
2. Product Name: / 5. Product Name:
3. Product Name: / 6. Product Name:

SPILL CLEAN UP, DISPOSITION & STORAGE

Services 119 and 140

/

Please indicate any specific procedures you would like Verisk 3E to follow with regards to spill cleanup. (Attach additional documents if necessary)

Type of Absorbents

Vermiculite / Sand / DE / Kitty Litter
Other:
Please indicate which, if any, dispositioning options may be advised when appropriate (e.g. if you have damaged paint cans you would like to donate to a charitable organization):
Facility Use /
Give to employees: /
Donate to charitable organizations
If so, please provide list of charity names below.
Charity/Name/Phone #: / Name/Phone #:
Other Disposition Options:
Does each facility have a hazardous waste storage area? / Yes No
If yes, where is it located?
Does each facility have Hazardous waste labels? Yes No

TRAINING AND RESOURCES (excludes service 131)

Services 119 and 140

/

Training

None / General Awareness / 24-Hour / 40-Hour / Confined Space / Asbestos
Other:

Type of PPE

Gloves / Goggles / Half Face Respirator / SCBA
Other:
Other:
Other:

EMERGENCY RESPONSE SERVICE (North America Only)

Yes No (If no, disregard the information below)

Service 120 Only / Do you wish to be notified before Verisk 3E dispatches an Emergency Response contractor to the site: Yes No
Do you have a preferred Emergency Responder contractor with an active contract? If yes, please list. If no, a 3E Emergency Contractor will be utilized. / Yes No
ER Contactor Name: / Contact Name: / Phone Number:
ER Contactor Name: / Contact Name: / Phone Number:
ER Contactor Name: / Contact Name: / Phone Number:
Is there minimum monetary amount before the ER has to be re-evaluated and approved before continuing? / Yes No / If yes, what is the amount? $
If an ER is initiated do you prefer that the waste is left on site? Yes No Inquire with contact
Preferred Method for waste disposal: Incineration Landfill Other:
** NOTE: 3E’s standard method for disposal is incineration. If no boxes are selected above, your disposal process will default to “incineration”.
Are there any other disposal options for specific waste types? (if yes, please list): Yes No
Incineration Landfill Other:
Incineration Landfill Other:
Incineration Landfill Other:
Incineration Landfill Other:
NOTE: If an ER contractor is dispatched on behalf of the client then later cancelled by the client, the contractor may access a “stop fee” which will be billed to the client.
Global Incident Response Service: Verisk 3E phone number to be utilized on (Check all that apply)
Service 145 Only / SDS / Transportation Documents / Product Labels / Tremcards
Describe typical product packaging: (Check all that apply)
Bulk Packaging / Non-Bulk Packaging / Consumer Commodity
Other
General Description of types of products and hazards to be covered by this service:
Safety Data Sheet Submittal and Contact Information
Services 140, 141, 145; Optional for All Other Services / SDS Contact: / Contact Title:
Telephone Number: / Fax Number:
E-mail Address:
Mailing Address:
SDS will be provided to Verisk 3E via:

3E Protect /
Verisk 3E Authored (M)SDS /
FTP /
CD-ROM /
Client Website
Web Address:
Access Instructions:

Updated: October 2017