Contaminated Products Insurance (Food & Beverage)
Application / Proposal Form
Please answer All questions in Full.
Please provide All attachments where requested.
This Application / Proposal Form must be signed and dated by the authorised person responsible for obtaining this insurance.
(Please seek advice from your Head of Quality Assurance / Control when completing this form)
1. APPLICANT / PROPOSER
1.1.
Name of company and subsidiaries to be insured under this Policy:
1.2.
Company Address
http://www.
(Please complete the website address)
Contact Name for this Insurance:
Tel:
Fax/e-mail:
Tel:
Fax/e-mail:
Title / Position:
Contact Name for Head of Crisis Management Team:
(Details for Crisis Consultants to contact
for desk-top review of plans)
Date Company was first established / incorporated:
2.
INSURED’s INSURED BUSINESS INTEREST
Business Interest (Manufacturer, processor, bottler, distributor, importer, retailer, other, etc.):
Product / Type:
Meat
Poultry
Seafood
Bakery
Processed Meals
Fruit
Vegetables
Snack-food
Dairy/Milk
Other (Please Specify)
Anticipated Sales for the next 12 Months
(‘000s)
Actual Sales for last 12 months
(‘000s)
Total Number of Plants / Facilities:
Total Number of Product Lines:
Previous 12 months
(‘000s)
(Please provide itemised list of products manufactured on site)
Please list countries where the Applicant and/or Contract Manufacturers manufacture / processes product(s):
A.
D.
B.
E.
C.
F.
Camargue Underwriting Managers: Product Recall
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Please provide sales split as follows:
Geographical Sales (%)
Products (%)
USA / Canada
%
Branded
%
UK / Eire
%
Non-Branded
%
Europe
%
Own Label*
Asia / Pacific
%
Other
%
List Customer sales by (%) split
%
(*3RD Party Products)
List Suppliers
A
%
A.
B
%
B.
C
%
C.
D
%
D.
E
%
E.
(Please attach separate documents if space is not available on this form)
3.
PRODUCT DETAILS
3.1.
Product
Type
Please provide details on your products as follows:
Cooked, Raw Sales
Frozen,
(‘000)
Brined
Ambient,
Low /
High Acid.
Average Batch
Value
(‘000)
Average
Batch
Size
(‘000)
Shelf Life,
‘Best Before’
or ‘Use By’
(please specify)
Type of Packing Tamper
(Vacuum, Gas
Evident
Flushed, Souse Yes / No
Vide, Modified
Atmosphere
Packed, please
Detail)
Profit
Margin
%
3.2. Please provide a FULL listing of products (including % of overall sales) manufactured by a third party / contract
manufacturer:
(Please attach further information to this proposal if this space is not sufficient)
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3.3.
Are all products manufactured by a third party / contract manufacturer governed by HACCP?
Yes / No
3.4.
Are all product specifications of products manufactured by a third party / contract packer agreed by you?
Yes / No
3.5.
4.
Do you have any hold harmless agreements in relation to a third party manufacturing on you behalf?
Yes / No
If “YES”, please provide details:
QUALITY ASSURANCE / PREREQUISITES
4.1.
Do you have a Quality Assurance / Control Department?
Yes / No
4.2.
Do you have a formal, written, HACCP plan?
Yes / No
4.3.
Does the HACCP plan include all critical control points?
Yes / No
4.4.
Does the HACCP plan include Critical limits?
Yes / No
4.5.
Does the HACCP plan include a Decision Tree?
Yes / No
4.6.
Date HACCP was last reviewed / audited and by whom:
(Please attach copy of audit)
4.7.
Does the HACCP plan include Corrective Actions
(Please attach a copy of your HACCP plan)
4.8.
Please provide the Name, including relevant qualifications, of the person responsible for Quality Assurance / Control:
Name:
4.9.
….. / ….. / …..
Yes / No
Qualification:
Please provide details of your Pre-requisites (e.g. SSOPs, etc.):
(Please attach further information to this proposal if this space is not sufficient)
4.10. Have you, your premises, or products ever been the subject of complaint from a governmental body or food regulatory
body?
Yes / No
If “YES”, then please provide details:
4.11. Are internal and external food safety audits carried out?
(Please specify and attach details of major recommendations that have yet to be implemented)
Yes / No
4.12. How often are these audits carried out?
4.13. Do you audit your suppliers?
(If “NO”, please answer the question below)
Yes / No
4.14. If you do not audit your suppliers, do you require them to complete a self-assessment questionnaire?
Yes / No
4.15. Do all products (including labelling and packaging) comply with legal requirements for the countries in which they are
sold?
Yes / No
4.16. How many mock recalls are conducted by the Applicant annually?
4.17. Does the Applicant and its third party manufacturers / contract manufacturers hold a third party accreditation (ISO,
EFSIS, AUS-QUAL, BRC, etc.)? Please provide details:
5.
TESTING AND TRACEABILITY
5.1.
Do you have an on-site accredited laboratory? (see question below)
5.2.
If “YES”, is this laboratory capable of providing full chemical, microbiological and nutritional profiles?
Yes / No
Yes / No
5.3.
Do you have use of an external accredited testing laboratory providing full chemical, microbiological and nutritional
profiles?
Yes / No
If “YES”, please provide details:
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5.4.
Does an external accredited laboratory verify your own on-site accredited laboratory results?
Yes / No
5.5.
Is monitoring (control specification) carried out at critical control points?
Yes / No
5.6.
Do you sample test supplies and raw materials / components entering the plant?
Yes / No
5.7.
Please confirm that ingredients, additives and processing aids (such as flavourings, spices, extracts, etc.) are checked
for the presence of allergens.
Yes / No
5.8.
Do you operate a positive release process for all products?
Yes / No
5.9.
Do you monitor and check labelling for allergens, instructions for use, etc.?
Yes / No
5.10. Is stress and suitability testing completed on product packaging?
Yes / No
5.11. Please complete the following table by marking with a tick:
RAW MATERIALS
CRITICAL CONTROL
POINTS
END PRODUCT
TESTING
VISUAL
VISUAL
MICROBIOLOGICAL
METAL DETECTORS
X-RAY
CHEMICAL
5.12.
Do you utilise a batch / lot coding system?
Please provide details:
Yes / No
5.13.
Can you trace your completed product from raw material receipt to despatch?
Yes / No
5.14.
Can you trace your completed product forwards through your customers?
Yes / No
5.15.
How often do you test the traceability system?
5.16.
Please outline the traceability system you use:
(Please attach further information to this proposal if this space is not sufficient)
5.17.
Do you have clearly defined high and low risk areas to reduce / prevent cross contamination?
Yes / No
5.18.
Do you make provision for the strict control and separate storage of known allergen material?
Yes / No
5.19.
Do you have total separation from other production area for the production of allergen free products?
Yes / No
5.20.
Are all food personnel fully trained in food safety and hygiene matters commensurate with their work?
No.: ………
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6.
EMPLOYEE, SECURITY and TRAINING, PRODUCT SECURITY
6.1.
Have you ever been the target, directly or indirectly, of any single issue protest group?
(e.g., PETA, ALF, SHAC or other) If “YES”, please provide details:
Yes / No
6.2.
Have you ever been politically, criminally or racially targeted?
If “YES”, please provide details:
Yes / No
6.3.
What percentage of your workforce during the course of a 12 month period is seasonal?
6.4.
Do all you plants have clear hygiene signage (in relevant languages for the workforce)?
Yes / No
6.5.
Do you have a staff vetting policy?
Yes / No
6.6.
Have you experienced any employee disputes, plants closures, strikes in the last 5 years
If “YES”, please provide details:
Yes / No
6.7.
In the next 12 months are there any plans to reduce the workforce, close a plant(s), or relocate?
%
Yes / No
If “YES”, please provide details:
7.
PLANS
7.1.
Please confirm that you have the following and attach copies:
7.1.1. Recall Plan
Yes / No
7.1.2. Crisis Plan
Yes / No
7.1.3. HACCP Plan
Yes / No
7.1.4. FSMA Verification Procedure Plan
Yes / No
7.1.5. How often are all your plans reviewed and updated?
Please provide details:
8.
LOSS HISTORY
8.1.
In the last 10 years have you recalled, or withdrawn, any products for which you have incurred costs or have
incurred costs on behalf of a third-party whatsoever?
Yes / No
If “YES”, please attach a full explanation of loss(es) including the following:
8.1.1.
8.1.2.
8.1.3.
8.1.4.
8.1.5.
the product(s) involved,
cause of loss,
full quantum breakdown of loss (transportation, warehousing, destruction, etc.
recoveries against third parties,
remedial action taken to prevent further losses occurring again.
8.2. Do you know of any situation that may lead to a claim under a contaminated products insurance policy?
Yes / No
If “YES”, please provide details:
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As part of the Contaminated Products Insurance Policy, Camargue Underwriting Managers provides risk management and
response services to the Insured through our Value Added Services. These services are provided to assist the Insured with their
response to a potential or actual Insured Event at no extra expense to the Insured and is not subject to the Retention.
Please provide the best point of contact in your organisation for the Retained Consultants to discuss this with:
Name:
Email:
Telephone Number
(This section ensures compliance with the Consultant Communications Endorsement)
9.
LIMIT / RETENTION
Please provide your preferred limit(s) and retention(s) below:
9.1.
Limit
9.1.1.
9.1.2.
9.2.
__________________
__________________
Deductible / Retention
9.2.1.
9.2.2.
10.
Product Contamination
(Incl. Malicious Product Tamper)
Product Extortion
Product Contamination
(Incl. Malicious Product Tamper)
Product Extortion
__________________
__________________
DECLARATION
I declare that after full enquiry, the contents of this proposal are true and that I have not misstated, omitted or suppressed any material fact
or information. I agree that this proposal together with any other information supplied by me shall form the basis of any contract of insurance
which may be affected. If there is any material alteration to the facts and information which I have provided or any new material matter
arises before completion of the contract of insurance, I undertake to inform insurers. I hereby consent to any information I have provided
being processed by you for the purposes of providing insurance claims handling, which may necessitate sharing such information with third
parties.
Signature:
Title:
Date:
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