/ APPLICATION FOR PRODUCT TAMPERING AND ACCIDENTAL CONTAMINATION INSURANCE
SHOREPOINT INSURANCE SERVICES
1120 BRISTOL STREETCOSTA MESA, CA92626
800-350-5647 / 714-430-0035 / FAX: 714-430-0036
CA LICENSE 0K07568

NAME OF APPLICANT: DATE:

ADDRESS OF APPLICANT: TELEPHONE:

APPLICANT CONTACT: FAX:

APPLICANT E-MAIL/WEB:

INDIVIDUAL / PARTNERSHIP / CORPORATION / JOINT VENTURE
“S” CORP / LL CORP / NON-PROFIT / YRS IN BUSINESS:
TOTAL REVENUES: $ / TOTAL # OF EMPLOYEES:
TYPE OF OPERATION:
PROCESSOR / ☐ / CO-PACKER / ☐ / SUPPLY INGREDIENTS / ☐ /
BOTTLER / ☐ / IMPORT/EXPORT / ☐ / DISTRIBUTOR / ☐ /
PACKAGING / ☐ / MANUFACTURER / ☐ / OTHER / ☐ /
DESCRIBE IN COMMENTS
REVENUE BREAKDOWN BY PRODUCT LINE (PAST 3 YEARS):
PRODUCT LINE / REVENUES / YEAR / REVENUES / YEAR / REVENUES / YEAR
$ / $ / $
$ / $ / $
$ / $ / $
$ / $ / $
$ / $ / $
GEOGRAPHIC BREAKDOWN OF REVENUES:
COUNTRY / PRODUCT LINE / % OF REVENUES

PAGE TWO

INSURANCE APPLICANT:

PACKAGING AND SHELF LIFE OF PRODUCTS:
PRODUCT / PACKAGING DESCRIPTION / AVERAGE SHELF LIFE

LIST LOCATIONS OF MANUFACTURING FACILITIES:

(1) / (3)
(2)
(4)
(A) PRODUCTS BACTCH PRODUCED? / OR IS IT A CONTINUE PROCESS?
IF BATCH PRODUCED, WHAT IS YOUR AVERAGE BATCH SIZE?
(B) IF CONTINUING PROCESS IS USED, WHAT IS YOUR AVERAGE SIZE RUN?
DOES YOUR CODING SYSTEM ALLOW FOR THE FOLLOWING IDENTIFICATION?
PRODUCT NAME:
MANUFACTURER: / DATE OF MANUFACTURE:
SERIAL NUMBER:
BATCH NUMBER:
OTHER:
(A) IF ANY PRODUCTS BECOME PART OF ANOTHER COMPANY’S PRODUCT, PLEASE PROVIDE DETAILS
OF SUCH, AND TO WHOM SOLD?
(B) IF ANY OF YOUR PRODUCTS ARE SOLD TO BE REPACKAGED UNDER ANOTHER NAME, TO WHOM
ARE THEY SOLD AND WHAT IS THEIR EVENTUAL NAME?
DO YOU INDEMNIFY OR HOLD HARMLESS BY CONTRACTUAL AGREEMENT ANY SUPPLIERS OF COMPONENTS OR RAW MATERIALS?
DO YOU MAINTAIN ANY FORM OF DATA PROCESSING INVENTORY CONTROL SYSTEM FOR:
PRODUCT INVENTORY / SALES TO AND IDENTIFY OF WHOLESALER
DISTRIBUTORS / RETAILERS
PAGE THREE
INSURANCE APPLICANT:
DO YOUR WHOLESALERS AND/OR DISTRIBUTORS MAINTAIN RECORDS OF THE FINAL RETAIL OUTLET OF YOUR PRODUCTS? YES NO
(A) DO YOU HAVE A RECALL AND/OR CRISIS MANAGEMENT PLAN ESTABLISHED TO HANDLE A RECALL IF ONE BECOMES NECESSARY? PROVIDE A COPY OF THE PLAN OR PROVIDE DETAILS:
(B) IF YOU DO NOT HAVE SUCH A PLAN AND IT BECOMES NECESSARY TO RECALL ANY OF YOUR
PRODUCTS, WHAT METHODS WOULD BE USED TO SECURE RETURN OF SUCH PRODUCTS?
(C) DO YOU PERFORM MOCK RECALLS? YES ☐ NO ☐
(D) DO YOU USE OUTSIDE PR CONSULTANTS YES ☐ NO ☐
(E) HAVE YOU UPDATED YOUR PLANS IN THE LAST TWO YEARS? YES ☐ NO ☐
HAVE YOU EVER BEEN A TARGET OF POLITICAL, ENVIRONMENTAL, RACIAL OR OTHER INTEREST GROUPS? YES NO IF YES, PROVIDE DETAILS:
DO YOU USE ANIMAL TESTING IN YOUR PRODUCT RESEARCH OR DEVELOPMENT? YES NO IF YES, PROVIDE DETAILS:
HAVE YOU EXPERIENCED ANY STRIKES, WORKSTOPPAGES, FACILITY CLOSING OR MAJOR RESTRUCTURING WITHIN THE PAST TWELVE (12) MONTHS?
YES NO IF YES, PROVIDE DETAILS:
HAVE ANY OF YOUR PRODUCTS EVER BEEN RECALLED DUE TO A PRODUCT TAMPERING OR EXTORTION? IF SO, STATE:
PRODUCTS INVOLVED:
REASON FOR RECALL: / TOTAL EXPENSE INCURRED: $
DATE RECALL INITIATED:
METHODS USED TO EFFECT RECALL:

PAGE FOUR

INSURANCE APPLICANT:

DO YOU, OR ANY OF YOUR DIRECTORS OR OFFICERS, HAVE KNOWLEDGE OR INFORMATION OF ANY FACT OR CIRCUMSTANCE WHICH MAY GIVE RISE TO A CLAIM UNDER THE PROPOSED POLICY?
YES NO IF YES, PROVIDE DETAILS.
(A) REQUESTED LIMITS OF INSURANCE –
PRODUCT TAMPERING / (B) REQUESTED LIMITS OF INSURANCE –
ACCIDENTAL CONTAMINATION
$ / EACH LOSS / $ / EACH LOSS
$ / EACH YEAR AGGREGATE / $ / EACH YEAR AGGREGATE
(A) REQUESTED DEDUCTIBLE / (B) REQUESTED DEDUCTIBLE
$ / $
IF YOU WANT ACCIDENTAL CONTAMINATION COVERAGE, PLEASE ANSWER THE FOLLOWING:
PLEASE INDICATE WHAT PERCENTAGE OF YOUR OPERATION IS:
A. / FOOD PROCESSING/MANUFACTURING
(A) DAIRY / % / (E) BAKED GOODS / %
(B) POULTRY / % / (F) VEGETABLES / %
(C) SEAFOOD / % / (G) FRUIT / %
(D) OTHER MEAT / % / (H) OTHER / % / SPECIFY:
FRESH / % / FROZEN / % / CANNED / %
B. / BEVERAGE PROCESSING/MANUFACTURING
DAIRY / % / OTHER / % / SPECIFY:
C. / PHARMACEUTICAL MANUFACTURING / %
D. / RESTAURANT / %
E. / TOBACCO PROCESSING/MANUFACTURING
F. / COSMETICS MANUFACTURING / %
G. / OTHER / % / SPECIFY:
HAVE ANY OF YOUR PRODUCTS EVER BEEN RECALLED DUE TO AN ACCIDENTAL CONTAMINATION? IF SO, STATE:
PRODUCTS INVOLVED
REASON FOR RECALL
DATE RECALL INITIATED / DATE RECALL CLOSED
METHODS USED TO EFFECT RECALL
TOTAL EXPENSE INCURRED / $
PAGE FIVE
INSURANCE APPLICANT:
DO YOU HAVE QUALITY CONTROL PROCEDURES SUCH AS THE U.S./FDA HACCP, SERVSAFE, ETC., PROGRAM IN PLACE?
ARE THERE ANY GOVERNMENTAL REGULATORY AGENCIES WITH OVERSIGHT RESPONSIBILITY FOR YOUR OPERATIONS (I.E. U.S. FDA, USDA, ETC.)?
YES NO IF YES, PLEASE LIST:
HAVE YOU EVERY BEEN CITED OR ISSUED A SUMMONS OR NOTICE OF ANY TYPE IN THE PAST FIVE (5) YEARS FOR VIOLATION OF REGULATIONS, PROCEDURES, ETC., OF ANY GOVERNMENTAL REGULATORY AGENCY WITH OVERSIGHT RESPONSIBILITY FOR YOUR OPERATION?
YES NO IF YES, PROVIDE DETAILS:

ADDITIONAL COMMENTS

NAME: / TITLE: / DATE:
/ Copyright © 2015-2016 Shorepoint Insurance Services, All Rights Reserved. Ed. 05 16
The Insurance Program Administrator reserves the right to refuse an applicant’s participation in the Insurance Program. / 1