Healthcare Pollution Liability

Healthcare Pollution Liability Insurance Application

Steadfast Insurance Company Dover, Delaware

For inquiries, please contact your broker or Steadfast at: P O Box 10630, Jacksonville, FL 32247 Telephone: (800) 713-1158 Fax: (888) 828-9427 Email address: [email protected] Web site address: www.hcpliability.com

This is an application for a CLAIMS-MADE insurance policy. Please complete one form per location. A separate application is required for each location if multiple facilities are to be insured.

I. General information

1. Named Insured 2. D&B D-U-N-S or FEIN number

3. Address

City State ZIP code

4. Telephone number 5. Fax number

6. Contact 7. E-mail address

II. Brokerage/Agency information

Please provide brokerage/agency information, if applicable. 8. Insurance agency

9. Address

City State ZIP code

10. Telephone number 11. Fax number

12. Contact 13. E-mail address

STF-HCP-101-C (7/04) Page 1 of 7 STF-HCP-101-C (7/04) Page 2 of 7 III. Facility/Location information

Please provide a separate application for each location. 14. Facility name/ID number

15. Address

City State ZIP code

16. Telephone number 17. Fax number

18. Contact 19. E-mail address

20. Indicate which description best reflects the applicant’s site use: Dentist office Physician office Out-patient healthcare clinic Veterinarian office For profit hospital Not for profit hospital Other (specify)

21. Is there any intended site use changes planned during the proposed policy period? Yes No If “Yes,” please explain the proposed use and when it will occur

22. Indicate all facility operations and exposures that apply: Diagnostic lab Microbiology lab Pathology lab Dialysis unit Nuclear medicine Radiology Above ground storage tanks Underground storage tanks Wastewater treatment plant Septic system, septic holding tanks, or leaching fields On-site waste disposal On-site waste treatment/sterilization Other(s) (specify)

23. If there is an on-site incinerator complete a. b. and c. below. a. Did construction on this incinerator commence after June 20, 1996 or has the incinerator been modified after March 16, 1998 in accordance with 40 CFR Part 60? Yes No b. The maximum charge rate in pounds/hour is: Small (<200) Medium ( >200 to 500) Large ( > 500 — specify)

c. Does the incinerator process waste from off-site for parties other than the insured? Yes No 24. Number of medical personnel at this location: a. Full-time b. Part-time

STF-HCP-101-C (7/04) Page 3 of 7 25. Quantify on an annualized basis: a. Number of patient appointments, outpatient visits or emergency room visits b. Patient days

26. Do you use a third party to transport medical waste generated by your facility? Yes No a. If “Yes,” do you have written due diligence procedures in place to determine if the carrier transporting your medical waste is licensed and/or certified by the respective controlling local, state, and federal agency(ies) and/or authorities transport the material(s)? Yes No b. Are these records maintained in a central location and available for review? Yes No 27. Do you self transport any medical waste? Yes No If “Yes,” please describe (include type of waste, quantity of waste, type and number of vehicles)

28. Do you utilize a nonowned disposal facility for medical waste generated by your facility? Yes No a. If “Yes,” do you have written due diligence procedures in place to determine if the disposal site accepting your waste is licensed and/or certified by the respective controlling local, state, and federal agency(ies) and/or authorities to accept the insureds waste? Yes No b. Are these records maintained in a central location and available for review? Yes No

IV. Storage tank information

29. If you have any storage tanks with a capacity of greater than 110 gallons, complete the Tank Schedule which follows. The tanks MUST be scheduled in order to be covered by the policy. Tank Schedule Facility/Location ID

Tank registration or

unique identifier Does the tank meet current Yes No Yes No Yes No EPA compliance? Are there plans to remove the Yes No Yes No Yes No tank within the next three years? What is the original tank

installation date (mm/dd/yy) What is the tank reline or impressed current installation date (if applicable) What is the tank construction Fiberglass reinforced Fiberglass reinforced Fiberglass reinforced (see next page for additional plastic plastic plastic choices) STI-P3 STI-P3 STI-P3 Fiberglass clad steel Fiberglass clad steel Fiberglass clad steel Steel — Bare Steel — Bare Steel — Bare Steel — Cathodic pro- Steel — Cathodic pro- Steel — Cathodic pro- tection or interior tection or interior tection or interior lined lined lined

STF-HCP-101-C (7/04) Page 4 of 7 What is the tank construction Fiberglass Fiberglass Fiberglass (continued) Other Other Other

Is the tank single or double wall Single Double Single Double Single Double

What is the capacity of the tank in gallons

What are the current content(s) Empty Diesel Empty Diesel Empty Diesel of the tank Unleaded gasoline Unleaded gasoline Unleaded gasoline Kerosene Kerosene Kerosene Fuel oil Fuel oil Fuel oil Waste oil Waste oil Waste oil Unleaded/Diesel Unleaded/Diesel Unleaded/Diesel (compartmentalized) (compartmentalized) (compartmentalized) Other (specify) Other (specify) Other (specify)

What is the position of the tank AST UST AST UST AST UST (above ground [AST] or underground [UST]) What is the diking construction Earthen Earthen Earthen for AST Steel Steel Steel Sand Sand Sand Concrete Concrete Concrete None None None Other (specify) Other (specify) Other (specify)

What is the base construction Earthen Earthen Earthen for AST Steel Steel Steel Sand Sand Sand Concrete Concrete Concrete None None None Other (specify) Other (specify) Other (specify)

What type(s) of leak detection Automatic leak detection Automatic leak detection Automatic leak detection system(s) is used (please check Ground water montioring Ground water montioring Ground water montioring all that apply) Soil vapor monitoring Soil vapor monitoring Soil vapor monitoring Interstitial monitoring Interstitial monitoring Interstitial monitoring Manual tank gauging Manual tank gauging Manual tank gauging (sticking) inventory (sticking) inventory (sticking) inventory Statistical inventory Statistical inventory Statistical inventory reconciliation reconciliation reconciliation Simplicity® Simplicity® Simplicity® Electronic line leak Electronic line leak Electronic line leak detection detection detection Other (please specify) Other (please specify) Other (please specify)

STF-HCP-101-C (7/04) Page 5 of 7 PLEASE NOTE: Tightness test documentation is required for underground tanks that are five (5) years or older, and do not have an automatic leak detection system. Test must show passing results and be within the last year.

V. Retroactive date, limits and deductible

Please indicate the following. 30. Retroactive date Policy inception Other — specify date

To obtain retroactive coverage, please provide a copy of prior pollution policies for the corresponding time period. 31. Policy limits $1,000,000/1,000,000 $1,000,000/2,000,000 $2,000,000/2,000,000 $5,000,000/5,000,000 Other $

32. Deductible level $500 $5,000 $10,000 $25,000 $50,000 Other $ Minimum deductible for hospitals and clinics is $10,000. Minimum deductible for all other facilities is $500. To obtain a deductible of $50,000 or greater, please include audited financial statements for the past two (2) years.

VI. Claims

33. Within the last five (5) years, has there been a discharge, dispersal, release or escape of any solid, liquid, gaseous or thermal irritant, contaminant or pollutant including smoke, vapor, soot, fumes, acids, alkalis, chemicals and waste, including but not limited to medical waste at the scheduled location to the best of your knowledge? Yes No If “Yes,” please attach a detailed description. If remediation has been completed, please provide a case closure letter from the state regulatory agency or your environmental consultant. If cleanup is not yet complete, please provide the following information from your latest environmental engineering report: cover page, executive summary, conclusion, and a site diagram detailing the contamination at the site. 34. Within the last five (5) years, has the applicant been the subject of third party liability claims as a result of a pollution event from a nonowned disposal facility to the best of your knowledge? Yes No 35. Are there any statutes, standards, or other city, state, or federal regulations relating to the environment which the applicant cannot currently comply? Yes No If “Yes,” please attach details.

VII. Warranty

36. At the time of signing this application, is the applicant aware of any circumstances which may reasonably be expected to give rise to a claim under this policy? Yes No If “Yes,” please attach details.

The applicant represents that all statements in this application, including the attached tank schedule(s), are true and correct to the best of their knowledge and that no material or relevant facts have been suppressed or misstated and agrees that the policy, if issued, will be issued on the reliance of such representations. The applicant represents that due diligence has been conducted to know of the information listed on this application.

Notice to Arkansas and Louisiana Applicant “Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false information in any application for insurance is guilty of a crime and may be subject to fines and confinement in prison.”

STF-HCP-101-C (7/04) Page 6 of 7 Notice to Colorado Applicant “It is unlawful to knowingly provide false, incomplete, or misleading facts or information to an insurance company for the purpose of defrauding or attempting to defraud the company. Penalties may include imprisonment, fines, denial of insurance, and civil damages. Any insurance company or agent of an insurance company who knowingly provides false, incomplete, or misleading facts or information to a policyholder or claimant for the purpose of defrauding or attempting to defraud the policyholder or claimant with regard to a settlement or award payable from insurance proceeds shall be reported to the Colorado Division of Insurance within the department of regulatory agencies.” Notice to Florida Applicant “Any person who knowingly and with intent to injure, defraud, or deceive any insurer files a statement of claim or an application containing any false, incomplete, or misleading information is guilty of a felony of the third degree.” Notice to Kentucky Applicant “Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance containing any materially false information or conceals, for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act, which is a crime.” Notice to Maine Applicant “It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the purpose of defrauding the company. Penalties may include imprisonment, fines or a denial of insurance benefits.” Notice to Nebraska Applicant “No misrepresentations or warranty made by the insured or on his behalf in the negotiation or application of this policy or contract of insurance shall defeat or void the policy or contract or effect the company’s obligation under the policy or contract unless such mis- representation or warranty: 1. was material; 2. was made knowingly with the intent to deceive; 3. was relied and acted upon by the company; and, 4. deceived the company to its injury. The breach of a warranty or condition in any contract or policy of insurance shall not void the policy or allow the company to avoid liability unless such breach exists at the time of the loss and contributes to the loss.” Notice to New Jersey Applicant “Any person who includes any false or misleading information on an application for an insurance policy is subject to criminal and civil penalties.” Notice to New Mexico Applicant “Any person who knowing presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be subject to civil and criminal penalties.” Notice to New York Applicant “Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information, or conceals, for the purpose of misleading, information concerning any fact material thereto, commits a fraudulent insurance act, which is a crime and shall also be subject to a civil penalty not to exceed five thousand dollars and the stated value of the claim for each such violation.” Notice to Ohio Applicant “Any person who with intent to defraud or knowing that he/she is facilitating a fraud against any insurer, submits an application or files a claim containing a false or deceptive statement is guilty of insurance fraud.” Notice to Oklahoma Applicant “WARNING: Any person who knowingly, and with intent to injure, defraud or deceive any insurer, makes any claim for the proceeds of an insurance policy containing any false, incomplete or misleading information is guilty of a felony.” Notice of Pennsylvania Applicant “Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information or conceals for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act, which is a crime and subjects such person to criminal and civil penalties.” Notice to Tennessee Applicant “It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the purpose of defrauding the company. Penalties include imprisonment, fines and denial of coverage.”

STF-HCP-101-C (7/04) Page 7 of 7 Notice to Virginia Applicant “It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the purpose of defrauding the company. Penalties include imprisonment, fine and denial of insurance benefits.” Notice to Washington D.C. Applicant “It is a crime to provide false or misleading information to an insurer for the purpose of defrauding the insurer or any other person. Penalties include imprisonment and/or fine. In addition, an insurer may deny insurance benefits if false information materially related to a claim was provided by the applicant.” Notice to All Other State Applicants “Any person who knowingly includes any false or misleading information for an insurance policy commits a fraudulent act and is subject to fines, imprisonment, or other criminal or civil penalties.”

Completion of this form does not bind coverage. The applicant's acceptance of a quotation is required prior to binding coverage and policy issuance. It is agreed that this application shall be the basis of the contract of insurance, should a policy be issued, and will become part of the policy. The applicant represents that due diligence has been conducted to know of the information listed on this application.

Applicant’s signature (applicant’s authorized signature of a principal partner, director, officer or owner)

Title Date (mm/dd/yy)

STF-HCP-101-C (7/04) Page 8 of 7