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
Yes
No
Yes
No
Yes
No
Yes
No
Year
Daily Production (DKK / € / $)
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
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
Page 1 of 4
€
Own label / brand name
€
€
Foreign label / brand name
€
3. Quality Control and Assurance
Do you have a written, in-force
Assurance Plan?
Did you install HACCP for all
products?
Yes
No
If yes, please add a copy
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
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
Page 2 of 4
If not, do you have an outside testing
laboratory?
Yes
No
Does testing occur at critical control
points?
Yes
No
Is there an incoming quarantine
process?
If yes, please specify
Yes
No
Yes
No
6. Audits
Are labels inspected?
If yes, by
Do your customers stipulate that
certain tolerance levels for errors are
maintained?
Have the tolerance levels ever been
exceeded?
Yes
No
If yes, please provide state level
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
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
Page 3 of 4
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
Page 4 of 4