ENVIRONMENTAL, SOCIAL IMPACT QUESTIONNAIRE
Application code: ……………………
I) CLIENT INFORMATION
Applicant name:
………………..……………………………………………………….………………………….………………
Exporter (investor) name:
.…………………………………………………………………………………………………….……
…………
Main Contractor 
Role of the exporter(investor):
Supplier 
Will other ECAs take part in the transaction?
(please specify)
Sub Contractor 
Joint Venture 
Yes 
No 
Unknown 
…………………………………………….
Is the exporter (investor) able to influence the design or specification of the goods/project?
Yes 
No 
II) PROJECT INFORMATION
2.1. Location of Project
2.2. Type of the project:
Country: ……………………….…. City:………………..…………………
New project
Extension/Modification 
Replacement 
If the project is an Extension/Modification or Replacement: Does the transaction cause material changes in the
output or function of the existing operations/project.
Yes  No 
Please provide details on additional page(s) with regard to the material changes in the output or function of the
existing operations/project and on the operational links with associated operations/project.
2.3. Project’s subject, description
…………………………………………………………………………………………………..
Please provide details on additional page(s) with regard to the subject of the commercial agreement (technical
description, site plan, overview plan, technological flow chart)
2.4. Impact Assessment
Has a Strategic Environmental Assessment been prepared (SEA)? Yes [] No [] Planned []
Has an Environmental Impact Assessment been prepared (EIA)? )? Yes [] No [] Planned []
If yes, does it fulfil the criteria of the World Bank/IFC on the EIA? (Sovereign/Private entity Debtor) )? Yes []
No [] Planned []
Is a Social Impact Assessment available? )? Yes [] No [] Planned []
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Is a Resettlement Action Plan available? )? Yes [] No [] Planned []
Is a Business Plan available? )? Yes [] No [] Planned []
Is a Feasibility Study available? )? Yes [] No [] Planned []
Is a Monitoring Report available? )? Yes [] No [] Planned []
If yes, please attach a copy or provide us with an electronic version; if planned, please specify a deadline.
2.5 Standards, permissions and other requirements
Has the Exporter any Quality or Environmental certification?
Yes  No 
If yes, please specify: ISO 9001/2  – ISO 14001  – EMAS  – ISO 14040  Other…………..
If yes, would the Exporter assure that the standard will apply to the current transaction? Yes  No 
Does the exporter maintain environmental, health and occupational safety management systems?
Yes  No 
Will the project comply with the host country environmental regulations?
Yes  No 
Will the project comply with the relevant internationally recognised standards,
Yes  No 
If yes please specify:
World Bank Safeguard Policies  – IFC Performance Standard  – MIGA’s Environmental Guidelines and
Policies  – RDB1  – EU  –Member’s Development Agency  – or other namely  ……….( please provide
details)
Any Environmental permit or authorization from the host country currently gaining?
Yes  No 
Has the project any legally binding environmental permit?
Yes  No 
Will the project location be a “protected area”2?
Yes  No 
Any negative effect on the surrounded area? (e.g.: resettlement)
Yes  No 
Will the project’s CO2 emission (including emission from direct and indirect sources) reach 50.000 ton per year?
Yes  No 
(If yes please attach a copy of the CO2 reduction plan, if that is not ready please specify a deadline)
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RDB =Regianal Development Banks: in particular, the European Bank for Reconstruction and Development, the Asian Development Bank,
the African Development Bank and the Inter-American Development Bank.
2
Tropical forest, national parks, nature reserves, archaeological zones, World Heritage sites, coral reefs, etc. Projects which are planned to be
carried out in sensitive locations or are likely to have a perceptible impact on such locations, even if the project category does not appear
in the above list. Such sensitive locations include National Parks and other protected areas identified by national or international law, and
other sensitive locations of international, national or regional importance, such as wetlands, forests with high biodiversity value, areas of
archaeological or cultural significance, and areas of importance for ind Yesous peoples or other vulnerable groups. Projects involving the
involuntary resettlement of a significant number of affected people.
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III. ENVIRONMENTAL IMPACTS
3.1. Please specify the type of export
Export of goods 
Export of project, technology, know-how 
The next part is to be filled in only by exporting of project, technology or know-how.
3.2. The project site is currently a(n)
Greenfield area 
New industrial estate 
Existing industrial estate 
Urban area 
3.3. Has the impacted area of the project been identified?
If yes please attach the analysis of the environmental impact and the impacted area
3.4. Environmental impact specifications
1. Air emissions
2. Use and impact on water resources
3. Noise pollution (internal, external)
4. Sewage
5. Waste generation
5. Hazardous waste generation
5. Use and storage of hazardous materials
6. Use of previously exploited land
7. Other (please specify…………………………………..)
YES 
YES 
YES 
YES 
YES 
YES 
YES 
YES 
NO 
NO 
NO 
NO 
NO 
NO 
NO 
NO 
Not applicable
Not applicable
Not applicable
Not applicable
Not applicable
Not applicable
Not applicable
Not applicable








3.5. Please specify if the project affects or will affect the following areas:
 Sites in the World Biosphere Reserves Directory
 Sites on the UNESCO World Heritage list
 IUCN I-IV areas and red list species
 Semi-desert, desert areas
 Tropical and sub-tropical forests
 Rivers, lakes, shorelines, coral reefs, wetlands, mangroves
 National parks, domestically (host country) protected environments and excavation sites, culturally important
areas
 Investments on sensitive sites that will have a significant effect on the area
 Habitats of endangered plants and animals or areas of high concentrations of biodiversity
 Habitats of vulnerable ethnic groups, their basic natural and other resources (e.g. local tribes, ethnicities)
 Natural habitats untouched by humans
 Areas of dense population and considerable industrial activity where further development could create
significant environmental and social problems
 Other areas of local interest or sensitive locations
3.6. Please identify and quantify the annual consumption or extraction of natural resources by the project
and provide details relating to the following resources:
Metals and metal ores
Further details:
Annual consumption:
Minerals
Further details:
Annual consumption:
Coal
Further details:
Annual consumption:
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Oil
Further details:
Annual consumption:
Gas
Further details:
Annual consumption:
Forest products
Further details:
Annual consumption:
Electrical power
Further details:
Annual consumption:
Water
Further details:
Annual consumption:
3.7. Please identify and quantify the annual production or use by the project of greenhouse gases, ozone
depleting substances, hazardous substances or persistent organic pollutants (POPs):
Carbon-dioxide
Further details:
Annual emission:
Methane
Further details:
Annual emission:
Other greenhouse gases (sulphur hexafluoride, hydrofluorocarbons and perfluocarbons)
Annual emission:
Further details:
Hazardous substances
Further details:
Annual consumption/emission:
Persistent organic pollutants
Further details:
Annual consumption/emission:
3.8. Any related or associated facilities*/investments connected to the project?
YES 
NO 
Further details:……………………………………………………………….
3.9. Public hearing related to the project’s environmental impacts has been conducted
YES  NO 
Further details:……………………………………………………………….
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IV. SOCIAL AND HUMAN RIGHTS IMPACTS
4.1. Any social or human right Due Diligence (analysis policy, standard or procedure) followed by
the exporter?
YES []
NO []
Please specify
………….……………………………………………………………………………………………………………………………….
..………………………………………………………………………………………………………………………………………….
4.2.
Will the project, or any of its associated facilities cause, require or bring about any of the following?
1. Resettlement (physical or economic) of the local population
YES []
2. Acquisition of land, or expropriation
YES []
3. Damage to livelihood or a way of life (e.g. agricultural, fishing, hunting
YES []
4. Impact on minority or vulnerable groups, (ex. indigenous, tribal, women) YES []
5. Work conducted by migrant workers
YES []
6. Child labour, or employment of persons under the age of 18 (See: Annex 1) YES []
7. Bonded or forced labour (See: Annex 1)
YES []
8. Large scale of influx of workers
YES []
9. Use of armed personnel (private securuity firms, state security/ military)
YES []
NO []
NO []
NO []
NO []
NO []
NO []
NO []
NO []
NO []
Please provide details of any of the above points that apply (attach additional description if needed):
……………………………………………………………….
4.3. Which steps have been taken in identifying affected populations and impacts:
1. Collection of baseline data on impacted people
2. Mapping to identify features such as population settlements, agricultural lands, etc.
3. Census of affected people (with or without land title) registered according to location
4. Socioeconomic surveys of affected peoples (including migrant workers & vulnerable groups)
5. Inventory of lost or affected assets: household, enterprise, community level
6. Analysis of surveys and studies to determine compensation parameters
7. SIA, ESIA, RAP 2, or other, specify:
If you have responded yes above, please attach 1 pc od copy or if it is under elaboration please indicate finishing
date of documents.
4.4. What
is the total estimated number of people that will be expropriated or resettled or how many
people affected directly by the project
[
]
4.5. Will impacts of the project result in a material change in the local populations ‘livelihood’?
YES []
NO []
4.6. Are the affected people part of a vulnerable group, such as indigenous, tribal, ethnic minorities, etc.
YES []
NO []
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Impacted Factors
Project stages
Environmental elements
Earth
Water
Air
Wildlife
Environmental systems
Architecture
Ecosystem
Settlement
area
People
Landscape
Implementation
Production
Installation/
Land aquisition
Construction
Completion of
the construction
Related activities
Accidents
I. Operation
II. Related
activities maintenance
Accidents,
malfunctions
Abandonment
Note: please put an X where the export project impacts the given environmental elements, systems or people in the different project stages
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The exporter declares that the environmental, social and human rights and greenhouse emission-elated impacts
of the export/project specified in points III.- IV of this Questionnaire:


do not exceed the threshold of the environmental and social standards applied (or are in compliance
with the environmental and social requirements)
exceed the threshold of the relevant standards (or are not in compliance with the environmental
requirements). Please specify……………………………………………………………………………..
The exporter further declares that the facts stated are, to the best of his knowledge, true and that he will be ready to
provide any further information related to environmental issues, if needed.
Date …………………
Signature and stamp
………………………………
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Guidance notes for
ENVIRONMENTAL, SOCIAL IMPACT QUESTIONNAIRE
Client information
1.1. the applicant’s name
The client who applies to Mehib for insurance. Eximbank or other commercial banks and the
client can apply to Mehib directly.
1.2. Exporter (investor) name
The investment’s exporter. The exporter who transfers investments, products, services and
technology to the host country.
1.3. Other information
The role of the exporter (investor)
The exporter is the main contractor or the subcontractor of the transaction.
Will other ECAs take part in the transaction?
Internationally is there any other insurer (ECA) involved in the transaction?
The exporter’s (investor) influence on the design or specification of the goods/project
Please specify if the insurer can request changes from the design and specification sides of the
project.
II. Project information
2.1. Project site
2.2. Project type
2.3. Project description
2.4. Impact Assesment
Strategic Environmental Assesment
In case of large-scale investments if the project influences the key sectors of the country – e.g.
energy distribution, infrastructure etc. – a comprehensive examination is needed to be
conducted with the focus on national and regional impacts (see EU DIR 2011/41/EC).
Environmental Impact Assesment
Environmental Impact Assesment that complies with the criteria provided by the host country
and the World Bank.
Social Impact Assesment
Resettlement Action Plan
To be filled in if the impacted residents need to be moved or resettled (see World Bank
criteria regarding content).
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Business Plan
Focuses on financing and profitability but it can contain relevant details about preliminary
estimates of environmental impacts, e.g. SWOT chapter.
Feasibility Study
Presents general technical, economical, social and environmental impacts
Monitoring Report
Controls the counteractions against environmental, social and human rights impacts during
the project and also considers the reports to the local authorities.
Other Studies
Cultural, Heritage Protection study, Biological study
2.5. Standards, Permits and other requirements
Quality or Environmental certifications
Maintaining environmental, health and occupational safety management systems
The project’s compliance with the host country environmental regulations
The project’s compliance with the relevant internationally recognised standards RDB = Regional Development
Banks, e.g. European Bank for Reconstruction and Development, the Asian Development Bank, the African
Development Bank and the Inter-American Development Bank
Gaining environmental permit or authorization from the host country
Legally binding environmental permit
Protected area
Negative effect on the surrounding area and people
The project’s CO2 emission – Direct source that loads the environment with the burning of fossil fuels; indirect
source that loads the global climate with the indirect use of an energy source e.g. electricity.
III. Environmental impacts
3.1. Export type
3.2. Project site
Greenfield investment
Natural sites under agricultural cultivation or forest management, green belt resting zones
and/or sites on which infrustructural development has not been conducted (roads, railraoads,
waterways etc.)
New Industrial Estate
The site is infrastructurally developed (there are utilities and service installations as well as
roads, railroads, waterways for transport). If a new industrial estate is developed exclusively
for the project offered for cover it is regarded as new development.
Existing Industrial Estate
The site is under commercial and/or industrial use and the Municipal Urban planning documentation specifies
the new function as such. The site is completely developed (there are utilities and service installations as well as
roads, railroads, waterways for transport).
Urban area
The investment is implemented on or in the immediate neighbourhood of a residential area.
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3.3. Identifying the impact area of the project
3.4. Environmental impact specifications
To be filled in by exporters of technologies, appliances, investments on fixed sites, facilities
or building complexes. We monitor the environmental impacts throughout the life cycle of the
product from its production to its waste state reviewing the influence of the insurer at different
stages.
1. Air emissions
2. Use and impact on water resources
3. Noise pollution (internal, external)
4. Sewage
5. Waste generation
5. Hazardous waste generation
5. Use and storage of hazardous materials
6. Use of previously exploited land
7. Other (please specify…………………………………..)
3.5. Specification of the project area.
Sites in the World Biosphere Reserves Directory
Sites on the UNESCO World Heritage list
IUCN I-IV areas and red list species
Semi-desert, desert areas
Tropical and sub-tropical forests
Rivers, lakes, shorelines, coral reefs, wetlands, mangroves
National parks, domestically (host country) protected environments and excavation sites,
culturally important areas
Investments on sensitive sites that will have a significant effect on the area
Habitats of endangered plants and animals or areas of high concentrations of biodiversity
Habitats of vulnerable ethnic groups, their basic natural and other resources (e.g. local tribes,
ethnicities)
Natural habitats untouched by humans
Areas of dense population and considerable industrial activity where further development
could create significant environmental and social problems
Other areas of local interest or sensitive locations
3.6. Specification of the use of natural resources
3.7. Use of greenhouse gases, ozone depleting substances, hazardous substances or
persistent organic pollutants (POPs):
3.8. Ancillary facilities/investments connected to the project
3.9. Public hearing and outcome
IV. SOCIAL AND HUMAN RIGHTS IMPACTS
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4.1. Any social or human right Due Diligence (analysis policy, standard or procedure) followed by
the exporter?
4.2. Will the project, or any of its associated facilities cause, require or bring about any of the following?
4.3. Which steps have been taken in identifying affected populations and impacts:
SIA – Social Impact Assessment
ESIA –Environmental and Social Impact Assessment
RAP – Resettlement Action Plan
4.4. What
is the total estimated number of people that will be expropriated or resettled or how many
people affected directly by the project
4.5. Will impacts of the project result in a material change in the local populations ‘livelihood’?
4.6. Are the affected people part of a vulnerable group, such as indigenous, tribal, ethnic minorities, etc.
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