Radioactive Material Supplementary Form – Ontario Broker  

radioactive material supplementary form – ontario broker:   broker no.:   producer:   applicant / named

Radioactive Material Supplementary Form –
Ontario

Broker:
 
Broker No.:
 
Producer:
 
Applicant / Named Insured:
 
Policy Number:
 
General
1.
Is the automobile being used in conjunction with a Nuclear Facility?
 
2.
Do you haul waste or a waste by-product which contains a nuclear
substance (radioactive material)?
 
3.
List the name and mass number of the nuclear substance (radioactive
material) and chemical compound which will be carried in the
automobile. Include the chemical name, atomic weight. E.g.: Cesium-137
or Cs-137. All quantities should be expressed in SI units. The base is
Becquerels and include the half-life.
 
4.
Is the nuclear substance (radioactive material) a liquid or gas or
solid?
 
5.
Do you require a licence or permit from a government agency or entity
to carry the described nuclear substance (radioactive material)? E.g.:
Canadian Nuclear Safety Commission.
 
If yes, has the licence or permit been obtained?
 
6.
Is the nuclear substance in a sealed device?
 
If yes, is the device portable (handheld) or fixed?
 
7.
Describe how the nuclear substance (radioactive material) will be
used.
 
File No.: 2012-00101
8.
Have all requirements in Transport Canada’s Transportation of
Dangerous Good Regulations and in the Canadian Nuclear Safety
Commission - Packaging and Transport of Nuclear Substance Regulations
been met?
 
9.
Do you have a Radiation Protection Program in place?
 
10.
Do you have a documented policy for loss or theft of a nuclear
substance (radioactive material)?
 
Driver Information
11.
List all drivers for the automobile(s) that transport a nuclear
substance (radioactive material). Include the driver name, licence
number and experience handling the nuclear substance (radioactive
material).
Driver Name
Licence Number
Experience
 
 
 
 
 
 
 
 
 
 
 
 
12.
Have all drivers that transport a nuclear substance (radioactive
material) been trained and have a valid Transportation of Dangerous
Goods (TDG) certificate?
 
13.
Has the Canadian Nuclear Safety Commission designated any of the
drivers as a Nuclear Energy Worker?
 
14.
Are drivers required to wear a radiation monitoring device?
 
If yes, provide a description of the device.
 
15.
Are drivers required to wear protective equipment and/or clothing
while transporting a nuclear substance (radioactive material)?
 
Automobile & Radius of Operation
16.
List the destination/facility that will be visited. (E.g.: Residential
Construction Site, Office Building, Nuclear Power Plant, Mine, Mill,
Hospital, University Campus, Airport, Brewery, etc.)
 
17.
List the automobile(s) that will require permission to carry a nuclear
substance (radioactive material) below.
Year
Make/Model
Body Type
VIN
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
18.
Are any of the automobile(s) listed above modified or customized?
 
If yes, describe the automobile and the modification/customization.
 
19.
What is the normal and maximum radius of operation for the
automobile(s) that transport a nuclear substance (radioactive
material)?
 
20.
Will the automobile(s) that carry a nuclear substance (radioactive
material) travel outside of Ontario?
 
If yes, specify the town or city and the corresponding province or
state.
 
21.
How often will the nuclear substance (radioactive material) be carried
within the automobile(s)?
Days per week:  
Days per month:  
22.
Do you carry the nuclear substance on a Year Round or Seasonal Basis?
Explain below.
 
23.
Describe how the nuclear substance (radioactive material) is packaged.
 
24.
Is a package comprised of multiple pieces?
 
If yes, explain and provide the piece count.
 
25.
How many packages which contain a nuclear substance (radioactive
material) will be carried per trip?
Normal:  
Maximum:  
This Supplementary Form is intended to provide information in addition
to that provided within the corresponding Ontario Application for
Automobile Insurance Owner’s Form (OAF 1). Consent and disclosure
provided within the corresponding Ontario Application for Automobile
Insurance Owner’s Form (OAF 1) extend to this Supplementary Form, and
the applicant acknowledges that the Ontario Application for Automobile
Insurance Owner’s Form (OAF 1) is based on the truth of the
information provided herein.
 
Applicant’s Signature
Date
 
Broker/Agent Signature
Date
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LHT0064 (04/12)