129804 · web viewif you import protein-based products (dairy, gluten, animal feed, eggs, etc…)...

SUBMISSION FORM CPIPlease fill in the information as accurately as possible. If you attach a BRC or IFS audit report with the application, the questions in the gray zones do not need to be filled inI. General information

Name of Applicant

Mailing address:

Contact Person Name

Website address: www.

Years in operation:

Operating currency US$ £ € other

Past Year Turnover:

Current Year Turnover:

Projected Turnover for term of policy: II. Type of operation (check all that apply)

Business Description:

Please check all that apply

Manufacture (own brands) Contract Manufacturer Bottler

Retailer Packaging Distributor/Wholesaler/ImporterIII. Coverage

ACI MPT Adverse Publicity Governmental Recall Other: All

Business Interruption Recall Coverage All

Limit: Deductible

Coverage desired for all products Yes NoIf no, list specified products to be covered in the table below and / or attach additional a page if necessary. Please continue to complete the application and referring only to the products specified below.Product Name Product Description Total annual sales

IV. Product Information

Product Category (check all that apply):

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Nuts/Snacks Dairy Fish/Sea Food Meat/Poultry

Grains (e.g. rice) Basic food ingredients Spices/Sugar Bakery

Fruits/Vegetables Ready to Eat Food coloring/flavors Confectionery

Beverage Baby food Performance food Other

What is the shelf life of your products (% of total sales)?

Up to 1 month 1 to 6 months 6 months to 1 year exceeds 1 year

Product is labelled as follows (% of total sales):

Own label (%) Third party label (%) Non-branded (%) What percentage of your sales is products intended to be used as a com-ponent or ingredient in the manufacturing of a third party product? %

Geographic breakdown of sales (%):

North America: Latin America Europe Japan

Australia & New Zealand Africa / Middle East China SE-Asia

V. Advertising & Merchandising Items

Do your products include advertising and merchandising items? Yes No

If Yes, please provide details to the following questions:

Do use them: Always Often From time to time

Only on special occasions

Those items are purchased by:

Those items are checked before they are purchased by the quality department? Yes NoVI. Customer Information

Please list your top 3 customer by sales

Customer Name Products suppliedType of business (retailer ,manufactor, wholesaler, other – please specify

% of Total Sales

VII. Manufacturing Information



VIII. Please complete for the top 3 selling products or product groups / categories

Top Selling Product #1



Name:

Total annual sales Is this product a finished product or Finished Ingredien Finished Ingredien Finished Ingredien

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intended to be sold as an ingredientProduct t Product t Product t

What is the shelf life What us the percentage of the total sales manufactured by a 3rd party?

Units Value Units Value Units ValueAverage manufactured lot*) size fort he top selling product (units and value) Largest manufactured lot size for the top selling products (units and value) *) Lot means a specific quantity of products manufactured or packaged during one manufacturing cycle under the same conditionsDoes the company use aseptic processing or packaging in any of the production facilities? Yes No

If yes, what percentage of products is aseptic: %

and what plants produce aseptic products

Does the company use glass bottles or jars in any of the production facilities? Yes No

If yes, provide the following:

Product description

% of revenue %

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IX. Production Information

Location

(city & country)

Third party

certification?

Top 3 Products

manufactured

Annual manufactured out-put (number of units pro-

duced AND value)Number of days/year plant oper-

ates

Number of production

lines/ product

Number of shifts / product

% unused capacity at

plantUnits Value

Yes No

1.)

2.)

3.)

Yes No

4.)

5.)

6.)

Yes No

7.)

8.)

9.)

Yes No

10.)

11.) 12.)

Yes No

13.)

14.)

15.)

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X. Supplier Information

Please indicate the geographic sourcing of raw materials/ingredients/supplies/packaging as a % of total



Do you have a Supplier Approval Program Yes NoDo you require your suppliers and / or third party or contract manufactures to have a HACCP program? Yes No

If No, please explain?

Are processes in place to assess the ability of your suppliers to meet your spectations?

Please check all that apply Yes No

Incoming quarantine Certificate of analysis Qualitying audit(s) by QWS statt or a third party

Requirement of liability or recall insurance certificate

Reviewing of government / consultant inspection reports

Purchasing requires written questionnaire and vetting of supplier

Please describe how you test received products to ensure that the ingredients conform to your specification?

Please complete for the top 3 suppliers (it imported from South East Asia or China complete question 22 too)

Name of Supplier Ingredient / material supplied Country of origin Annual Volume

supplied Supplier since

For the imported material/ingredients/finished products from SE Asia and/or China, complete table below

CountryDescribe material/ingredient or finished product

Amount of product annually (units/value)

Test performed to ensure product tree from contaminants

Frequency of testingUnits Value

If you import protein-based products (dairy, gluten, animal feed, eggs, etc…) or their derivatives from Asia, do you test for the presence of melamine, cyanuric acid or other possible “illegal” contaminants?

Yes No

Have you agreed to indemnify or hold harmless any supplier? Yes No

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If yes, please describe

Are your suppliers contractually obligated to indemnify you in the event of a product contam-ination caused by their products? Yes No

Do you require your suppliers to carry Product Liability Insurance? Yes No

If yes, what limits are they required to purchase?

Are you requiring to be added to their policy as additional insured? Yes NoDoes the Product Liability insurance provide indemnity for recall expenses and damage to your products if caused by a defective or contaminated ingredient? Yes No

Do you require your suppliers to carry Product Recall Insurance? Yes No

If yes, what limits are they required to purchase?

What coverage are they required to purchase? XI. Food Safety and Risk Management

Who is the contact person for Quality Assurance/Food Safety? Yes NoDo you have a written quality assurance plan, quality management system, Good Agricultural Practices, Good Manufacturing Practices or similar program? Yes No

Do you have a HACCP program for all products? Yes No

If No, please explain:

Was your HACCP plan reviewed and validated by a third party? Yes No

If yes, please indicate the third party

Has the HACCP Plan been revalidated when product/process changes have occurred? Yes NoIs the traceability system capable of linking lots of finished products to batches of raw materi-als and packaging used, and vice versa? Yes NoIf you receive Certificates of Analysis (CoAs), do you randomly test against them to ensure conformance? Yes No

If yes, what is the frequency of testing

and what is the percentage of shipments tested: %What features of the finished product make the product food safe (e.g. sterilisation, pH, water activity, MAP, pasteurisation …)? Please describe:

XII. Product Testing

With regard to the testing of your products, please mark the applicable boxes:

Type of Test Raw Materi-als

In-line during production End of line

Microbiological General

Pathogens

X-Ray

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Metal Detection

Chemical Quality criteria

Food Safety Cri-teria

Other linked to food safetyIf microbiological/pathogen tests are performed, is there a hold period before shipping? Yes No

What testing Laboratory does your company use: Internal Third Party

If Third Party (external), please provide name(s):

Has a third-party or government inspection/audit been performed in the past 12-18 months?

Yes No

If yes, has an audit or inspection performed at each location? Yes No

If no, please explain why:

What allergens are used in the production area?

Is there an allergen labeling with regards to the unintentional presence of allergen? Yes No

If yes, for which allergens?

XIII. Audit

Provide the following information if you are audited by a third-party:

Name of Third party Type of Audit(e.g. BRC, IFS, EFSIS)

Score or Rating Audit Date

Were there any recommendations deemed “critical” or “major”? Yes No

If yes, have they been taken care off Yes No

If no, please describe why:

What was the last date of a governmental agency or regulatory inspection?

Please describe and attach a copy of the report.

Have you ever received a regulatory warning letter? Yes No

If yes please provide a copy or a summary of the letter and corrective actions taken.

Have the company’s products or any of its premises ever been the subject of comment or complaint by any governmental agency or department?

Yes No

If “yes”, please complete the following:

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Agency or department involved

Date and nature of comment or complaint

Outcome of such comment or complaint

Date resolved XIV. Recall Risk Management and Business Continuity

Do you have a current recall plan? Yes No

If yes, date of the last update:

Please attach a copy of the current plan.

If no, please describe how you manage that all necessary products if needed can be withdrawn?

Are mock recall simulations conducted annually? Yes No

Please provide the date of the last simulation:

Is a batch coding system utilized? Yes No

If yes, please describe coding (e.g. Julian, date, hour, minute, shift, etc…)

Do you have a Business Continuity Plan in case of a Recall and or Production shut down installed?

Yes No

If yes, date of the last update:

XV. Malicious Product Tampering

Has a process security/bioterrorism audit been conducted? Yes No

Does the applicant comply with the applicable food security and bioterrorism guidelines issued by relevant regulatory agencies?

Yes No

Do you know of any actual, threatened or suspected malicious product tampering, or any actual or suspected accidental contamination involving any of your products during the last 5 years?

Yes No

If yes, please attach a summary of the details

Does the applicant import or export from politically volatile countries Yes No

If yes, please describe:

XVI. Loss History

In the past 5 years, have you had any voluntary product withdrawals or recalls, silent re-calls or contamination incidents exceeding EURO 25,000?

Yes No

If yes to any of the above, please provide the following information for each incident, use a

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separate sheet if necessary.Product

Cause of contamination / recall / MPT

Plant/location where incident (which triggered the loss) occurred

Was a product recall effected (Y/N)

Date of Recall

Total cost of the contamination / recall

# units recalled

Value of product recalled

Recall expenses (including consultants)

Business Interruption

Third party liability indemnity

Corrective action

Were any contracts lost/discontinued as a result? Yes No

If yes, please explain:

Does the company, its directors and officers or any other person known to the Insured have knowledge or information of any specific fact which may reasonably give rise to a claim under the proposed policy?

Yes No

If “yes”, please provide details

Estimate the cost to recall your leading brand:

Maximum: Minimum: Average:

XVII. Declaration

Note: SIGNING THIS PROPOSAL DOES NOT BIND THE PROPOSER TO COMPLETE THIS INSURANCE.

I declare that the statements and particulars in this proposal are true and that no material facts have been mis-stated or suppressed after enquiry. This includes the findings (positive and negative from the third party audits report, if applicable. I agree that this proposal, together with any other information supplied shall form the basis of any contract of insurance affected thereon. I undertake to inform the Insurers of any material alteration to those facts occurring before completion of the contract of insurance. A material fact is one which would influ-ence the acceptance or assessment of the risk.Signed Company

Title Date

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(to be signed by Chairman/Chief Executive or equivalent)

XVIII. Enclosures

Please enclose the following:

Recall Manuals/ Crisis Management Plan

HACCP Plan and flowcharts

Most recent third party audit

Most recent third party audit

All written statements and materials furnished to the Insurer in conjunction with the Proposal Form are hereby incorporated by reference into the proposal form and made a part thereof.

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129804 · web viewif you import protein-based products (dairy, gluten, animal feed, eggs, etc…)...

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