1. Business Activities and Turnover

Risk Analysis CPI
Contaminated Product Insurance

General Statements

Name of company
Address
Name of subsidiaries to be insured
(Please add separate sheet if necessary)
Website

1. Business activities and turnover

Business activities
Annual turnover / 2011
2012
Expected

2.a Products subject to this coverage

Product Line / Finshed Product / Year / Daily Production (DKK / € / $)
Yes No
Yes No
Yes No
Yes No

2.b Sales by country / manufactured in

USA/Canada / Export
€ / Manufactured in
Europe/Other countries / Export
€ / Manufactured in

2.c Please provide annual turnovers sold as part of or under another company’s label or brand name

Own label / brand name / €
€
Foreign label / brand name / €
€

3. Quality Control and Assurance

Do you have a written, in-force Assurance Plan? / Yes No
If yes, please add a copy
Did you install HACCP for all products? / Yes No
If yes, date HACCP last reviewed
Please add the final report of HACCP
Did you transform all seven HACCP principals? / Yes No
Do all products meet the registration standards / ISO 9000:2005 / ISO 9001:2008
ISO 9004:2009 / IFS-Certification

4. Quality Control

Is there a Quality Control Department? / Yes No
Do you have a central contact person within the relevant (governmental) authorities? / Yes No
If yes, please specify

5. Product testing

Please describe the procedures utilized by your company

Type of testing Products / Raw Materials / In-line / End-product
Microbiological / Yes No / Yes No / Yes No
X-ray / Yes No / Yes No / Yes No
Metal detectors / Yes No / Yes No / Yes No
Other: / Yes No / Yes No / Yes No
Other: / Yes No / Yes No / Yes No
Do you have an in-house testing laboratory? / Yes No
If not, do you have an outside testing laboratory? / Yes No
Does testing occur at critical control points? / Yes No
If yes, please specify
Is there an incoming quarantine process? / Yes No

6. Audits

Are labels inspected? / Yes No
If yes, by
Do your customers stipulate that certain tolerance levels for errors are maintained? / Yes No
If yes, please provide state level
Have the tolerance levels ever been exceeded? / Yes No
If yes, please provide details

7. Recall Preparedness

Do you have a Recall Plan? / Yes No
If yes, date of creation
Date of last revision
Do you use a batch coding system? / Yes No
If yes, please provide details
Who can initiate a major product recall?

8. Loss information

Have the insured products or its industrial premises ever been subject of comment or complaint by any governmental agency or department? / Yes No
If yes:
Authority
Date
Type
Outcome
Date resolved

9. Claims history of Company

a. Products recalled due to an accidental contamination in the last five years

Range and Product
Reason of Recall
Date of Recall
Recall method utilized
Cost of Recall

b. Products recalled for actual, threatened, or suspected malicious tampering in the last five years

Range and Product
Reason of Recall
Date of Recall
Recall method utilized
Cost of Recall
Which kind of sanctions did you encounter in order to prevent such claims?

10. 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

Declaration

I declare that the statements and particulars in this proposal are true and that no material facts have been misstated or suppressed after enquiry. 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 influence the acceptance or assessment of the risk.

(Place, Date)
/ (Signature / Function)
HDI Danmark,
Indiakaj 6, 1. DK-2100 København Ø
CVR.nr. 37 27 62 51
Telefon:+45 33 36 95 95
Danske Bank IBAN DK9530000011789501
Konto nr. 3001 11789501 / HDI Danmark,
Dansk filial af HDI Global SE, Tyskland.
HDI-Platz 1
30659 Hannover,
Germany

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