LIABILITY QUESTIONAIRE

SAWMILLS

  1. INSURED:______
  2. MAILING ADDRESS: ______

WEBSITE: ______

BROKER: ______LIMIT OF LIABILITY: ______

PREVIOUS INSURER: ______PREMIUM:______

TERM:______

  1. LOCATION OF MILL(S):______
  2. YEARS IN BUSINESS:______
  3. LOSS HISTORY (5 YEARS); ______
  4. NO. OF EMPLOYEES:______

ACTUAL PAYROLL: ______

W.C.B.ALL EMPLOYEES? Yes No

  1. SUB-LETLOGGING:______

HAULING:______

OTHER:______

CERTIFICATE OF INSURANCE:______

  1. LOGGING – OWN EMPLOYEES (RECEIPTS):______

IF 7 AND 8 – CONFIRM BUY LOGS:______

  1. RECEIPTS:

DOMESTIC:______+ FOREIGN:______

+ US:______= ______

ANY VALUE ADDED PRODUCTS?______US? ______

  1. UNLICENCED LOGGING, DUMPOR GRAVEL TRUCKS: ______
  2. WATERCRAFT?______
  3. WATERFRONT FACILITIES:

APPLICABLE MARINE COVERAGES: Yes No

WHARFINGERS? Yes No

SAFE BERTHING? Yes No

STEVEDORES LIABILITY? Yes No

TYPE OF VESSELS: ______NO. PER YEAR: ______

  1. RAILROAD SIDETRACK OR CROSSINGS? NO. PER YEAR:______
  2. ANY PRIVATE ROADS?______WHERE?______

POSTED? ______PROTECTED ACCESS?______

DO YOU HAVE A ROAD MANAGEMENT SYSTEM? Yes No

MAINTENANCE PLAN?If yes, please attach Yes No

  1. BEEHIVE BURNERS:______PROTECTION:______

AGE OF SCREEN?______SPRINKLERED?______

DISTANCE TO THIRD PARTY STRUCTURES OR WOODED AREA? ______

  1. TREATING:

(A) PRESERVATIVES______

(I.E. Railway Ties)

(B) USE OF TERRA AND PENTACHLOROPHENOL COMPOUNDS Yes No

  1. BOOMING AND SORTING GROUNDS? ______

WET OR DRY SORT? ______

NO. OF BOOMS?______REGULAR INSPECTION?______

  1. SUPPLIERS AND DISTRIBUTORS OF YOUR PRODUCTS:

1)DO YOU HOLD THEM HARMLESS OR INSURE THEM? Yes No

2)DO THEY HOLD YOU HARMLESS OR INSURE YOU? Yes No

If yes in either 1 or 2 above, please explain and provide copies of agreements

______

______

______

  1. ANY CHANGES IN OPERATIONS IN THE LAST 5 YEARS OR ANTICIPATED?______

______

  1. ANY PUBLIC TOURS? YesNO. PER YEAR: ______
  2. PRODUCTION BREAKDOWN:

(A) LUMBER______%(F) LOGS______%

(B) SHAKES/SHINGLES______%(G) PULP______%

(C) PLYWOOD/WATERBOARD______%(H) RAILWAY TIES______%

(D) VENEER______%

(E) OTHER______%(Describe) ______

  1. ALL MOBILE EQUIPMENT BEEN EQUIPPED WITH SPARK ARRESTORS?______
  2. SMOKING REGULATIONS?______CONTROLS?______

______

  1. WELDING REGULATIONS?______CONTROLS?______

______

  1. DISTANCE OF CLEAR SPACE AROUND OPERATIONS?
  2. ALL REPAIR CONTRACTORS FILE CERTIFICATES OF INSURANCE?______

LIMITS:______

  1. ALL CUSTOMERS CAUTIONED REGARDING IMPROPER USE OF TREATED WOOD? (I.E.)

INTERIOR USE AND PROTECTION FROM EXPOSURE TO ANIMAL FEED, FOOD AND

DRINKING WATER) ______

  1. LOSS PREVENTION

a) HAVE YOUR PRODUCTS EVER BEEN SUBJECT TO INQUIRY OR INVESTIGATION RELATIVE TO PRODUCT SAFETY BY ANY GOVERNMENT AGENCY? IF YES ATTACH DETAILS Yes No

b)DO YOU HAVE A WRITTEN PRODUCTS RECALL PLAN? IF YES, PLEASE ATTACH. Yes No

c)HAVE YOU EVER RECALLED PRODUCTS BECAUSE OF POTENTIAL PRODUCT SAFETY HAZARD?

IF YES, ATTACH DETAILS AND INDICATE PER CENT OF RECOVERY Yes No

.

d)HAS YOUR MANAGEMENT ISSUED A WRITTEN POLICY STATEMENT ON PRODUCT SAFETY WHICH HAS BEEN COMMUNICATED TO ALL EMPLOYEES? IF YES, PLEASE ATTACH. Yes No

e)DO YOU HAVE A WRITTEN PRODUCTS SAFETY PROGRAM FOR WHICH SPECIFIC INDIVIDUALS HAVE

RESPONSIBILITY FOR IMPLEMENTATION? IF YES, ATTACH COPY OF OUTLINE. Yes No

  1. QUALITY CONTROL

(a)ARE WRITTEN TESTING PROCEDURES FOLLOWED? Yes No

(b)DO YOU HAVE A QUALITY CONTROL MANAGER RESPONSIBLE ONLY TO TOP MANAGEMENT? Yes No

(c)SUPPLIES AND COMPONENTS:

1)ARE THEY ORDERED TO YOUR SPECIFICATIONS? Yes No

2)HAVE YOU DETERMINED WHICH ONES ARE CRITICAL? Yes No

3)LIST THOSE CRITICAL ITEMS, INDICATING WHETHER TESTING IS ON A SAMPLE

BASIS OR ON ALL UNITS: ______

______

______

4)ARE WARRANTIES OBTAINED FROM ALL SUPPLIERS? Yes No

d) FINAL PRODUCTS:

1)BRIEFLY DESCRIBE TESTS APPLIED BEFORE SALE: ______

______

2)WHAT PERCENTAGE IS TESTED?______%

3)ARE RECORDS OF RESULTS OF QUALITY CONTROL TEST KEPT SO THAT YOU CAN IDENTIFY AT A LATER DATE WHAT TESTS YOU APPLIED TO A GIVEN PRODUCT AT A GIVEN TIME? Yes No

4)HOW FAR BACK DO YOUR RECORDS GO? (GIVE DATE)______

Please clearly identify the person from which the above information was obtained.
______
The undersigned hereby affirms the accuracy and completeness of the information contained herein. The undersigned hereby applies for insurance and agrees that any non-disclosure or material misrepresentation of pertinent facts may render any such insurance contract null and void at the insurer’s discretion.

READ AND ACCEPTED BY:

X______

Name and Title of Applicant (not broker or agent)

X______

Signature

X______

Dated