HOUSTON CASUALTY COMPANY
MALICIOUS PRODUCT TAMPERING/ACCIDENTAL PRODUCT CONTAMINATION
RETAIL GROCERY OPERATIONS
SUPPLEMENTAL APPLICATION FORM
The protection you need to secure your brand’s reputation
1. What percentage of total revenue is derived from the following proprietary operations:
Bakery ______% Deli ______% Meat______%
2. Do you own or operate any dairy facilities? Yes____ No____
If yes, how many?______And how sales revenue is derived annually from products
obtained from these facilities?______
3. What percentage of the ground beef sold at your store is purchased “case ready” from suppliers?______%
Do you ever mix the ground beef from one supplier with ground beef provided to you by one or more other
suppliers? Yes _____ No _____
Please describe briefly your on-premises testing procedures for ground beef and other meats/poultry and fish.
______
______
______
4. How many suppliers provide you with meat and/or poultry? ______
Of these suppliers, is there one supplier that provides you with 20% or more of the products you sell?
Yes ______No ______If yes, please explain ______
______
5. Briefly list the types of stores branded products (if any) manufactured by outside sources: ______
______
______
What do these products in total represent in terms of annual sales? ______
6. Concerning products imported from China, do you import any products (or any ingredients) or packaging
materials from China? Yes _____ No _____ If so, which ones? Please provide complete details. ______
______
What portion of your total sales figure relates to products imported from China? ______
Do you obtain them directly from the “source” in China or from another importer (“middle man”)? ______
______
What contractual arrangements are in place (if any) to protect you from the consequences (i.e. recall expenses and other items covered by our policy) of products from China supplied to you that come to you contaminated?
______
______
THE UNDERSIGNED AUTHORIZED CORPORATE OFFICER OF THE APPLICANT DECLARES TO THE BEST OF THEIR KNOWLEDGE THE STATEMENTS SETFORTH HEREIN ARE TRUE AND NO INFORMATION HAS BEEN WITHHELD.
Signed:
Title:
Date:
FORM MPT-APC(Ed.2-01) APPL
HCC Specialty, a division of HCC Insurance Holdings, Inc., is comprised of HCC Specialty Underwriters, Inc. and Professional Indemnity Agency, Inc.