Fillable Form 1.: POULTRY SUPPLEMENTAL APPLICATION (James Allen Insurance)

Fill Online, Printable, Fillable, Blank Form 1.: POULTRY SUPPLEMENTAL APPLICATION (James Allen Insurance) Form

Use Fill to complete blank online JAMES ALLEN INSURANCE pdf forms for free. Once completed you can sign your fillable form or send for signing. All forms are printable and downloadable.

Form 1.: POULTRY SUPPLEMENTAL APPLICATION (James Allen Insurance)

On average this form takes 72 minutes to complete

The Form 1.: POULTRY SUPPLEMENTAL APPLICATION (James Allen Insurance) form is 6 pages long and contains:

  • 0 signatures
  • 159 check-boxes
  • 215 other fields

Country of origin: US
File type: PDF

Use our library of forms to quickly fill and sign your James Allen Insurance forms online.

BROWSE JAMES ALLEN INSURANCE FORMS

Related forms
Fill has a huge library of thousands of forms all set up to be filled in easily and signed.
Fill in your chosen form
Sign the form using our drawing tool
Send to someone else to fill in and sign.
find another form
 
Poultry Supplement Application
Page 1 of 6
Edition 4/1/2019
PSA-0419
PSA-0419
___
___
___
___
___
___
___
___
___
___
___
___
___
___
___
___
___
___
___
___
___
___
___
___
___
___
___
POULTRY SUPPLEMENTAL APPLICATION
Note: All no answers or undesirable features should be referenced by question number and explained in the
comments section at the end of this application.
Applicant Name: Contact Name/Number:
1.
Current/ Prior Carrier:
2.
Losses in past 5 years? Yes No
Expiration Date: Expiring Premium:
3.
If yes, please describe in full detail:
*** (Three(3) year hard copy loss runs are required to bind coverage) ***
4.
How long has the applicant farmed?
5.
Does owner or farm manager live on site? Yes No
6.
How many years has the applicant owned a poultry farm?
7.
Name of the Poultry Integrator/Company that the applicant is contracted with?
8.
Has applicant contracted with any other Poultry Integrator/Company? Yes No a. If yes, how long?
b.
Why did they change?
c.
Does the insured contemplate any change in their Poultry Integrator/Company in the next 12 months?
9.
Building(s) are Occupied or Vacant?
If there are any vacant buildings are we being requested to insure them? Yes No
10.
What is the type of confinement operation? Commercial Eggs Pullets Breeder Hen Broiler
11.
Financial evaluation
a.
How many years has the applicant been with the integrator?
b.
What is the applicant’s standing with the Poultry Integrator/Company?
Top 10% 11%-33% Below 33% New Grower/Integrator Relationship
c.
Have the houses been without an integrator contract within the last 5 years? Yes No
d.
Type of contract with the poultry company (integrator)? Flock-to-Flock Multi-Year
End date
e.
How does the applicant typically settle when birds are processed?
Above Average Average Below Average
f.
How many flocks does the applicant raise per year?
g.
Have you been on any type of grower improvement program in the past 3 years? Yes No
If yes, please explain.
Page 2 of 6
Edition 4/1/2019
PSA-0419
PSA-0419
___
___
___
___
___
___
___
___
___
___
___
___
___
___
___
___
___
___
___
___
___
___
___
___
___
___
___
___
___
___
___
___
___
___
___
___
___
___
___
___
___
___
___
___
___
___
___
___
___
___
___
___
___
___
Is the generator weather protected and well ventilated?
Is the generator in a separate unconnected building?
b. Is the generator tested “under load” weekly?
Yes
Is a log kept? (must be provided upon loss)
Is the generator weather protected and ventilated?
Is the generator in a separate unconnected building?
No
Yes
Yes
12.
Have Safety programs been formalized for:
a.
Fire Control (fire extinguishers/ other systems)? Yes No
b.
Saw dust/shavings or hay storage (moisture control)? Yes No N/A
c.
Is there a Biosecurity plan (Controls in place to prevent disease and limit unnecessary exposures by
visitors)? Yes No
A written plan Verbal controls in place Biosecurity plan loosely followed
d.
Is there 24 hour on-site security (someone lives on premise full-time)? Yes No
e.
How do you dispose of your birds?
i.
If composting is there a spontaneous combustion prevention program in place? Yes No
f.
Do you use an ammonia product between flocks? Yes No
i.
If yes, is there environmental safety (ammonia control)? Yes No
13.
Generator
a. Do the confinement houses have an emergency backup generator with automatic transfer switch?
Yes No
es No
No
No
14.
Housekeeping and Maintenance
a.
Are confinement buildings cleaned out at least 1 time per year? Yes No
b.
Is housekeeping around all confinement buildings, sheds, barns, etc. free of excess debris and clutter?
Yes No
c.
Are Measures taken to control dust and cobwebs evident? Yes No
d.
Is the grass mowed and kept around all confinement buildings, sheds, barns, etc.? Yes No
e.
Are the control rooms clean and free of clutter (especially paper)? Any Flammables? Yes No
f.
Is there a rodent control program? Yes No
g.
Is there any evidence of rodents or rodent damage? Yes No
h.
Is the interior of confinement buildings free of non-essential items, clutter? Yes No
i.
How many portable fire extinguishers are in each poultry building?
(0) Zero (1) One (2) Two or more
j.
Is there a scheduled maintenance program? Yes No
k.
Is there a preventative maintenance program? Yes No
l.
Is smoking allowed on premise? Yes No
If yes:
Are there designated smoking areas outside only with proper receptacles?
Are there designated smoking areas without proper receptacles?
No smoking rules in place
Page 3 of 6
Edition 4/1/2019
PSA-0419
PSA-0419
15.
Construction
Building
1
2
3
4
5
6
7
8
Location
Building
name/reference
Vacant (Y/N - if Y, since
what date)
Year Built
Length
Width
Trusses/Legs
(wood/metal)
Roof Attachment
(screws/nails)
Distance between
trusses (inches)
Foundation *
construction
Hurricane straps
(Y/N)
Metal knee braces
(Y/N)
Wooden Knee Braces
(Y/N)
Are knee braces
properly installed?
(Y/N)
Year Electric upgrades
Year Mechanical
upgrades
Perils
Limit of Insurance
Valuation (ACV/RC)
Deductible
Earthquake
Mine Subsidence (Y/N)
* Foundation Construction: TL= Treated Lumber C=Concrete CB= Combination
Page 4 of 6
Edition 4/1/2019
PSA-0419
PSA-0419
___
___
___
___
___
___
___
___
___
___
___
___
___
___
___
___
___
___
___
___
___
___
___
___
___
___
___
___
___
___
___
___
___
___
___
___
___
___
___
___
___
___
16.
Structural Evaluation
a.
Confinement houses built by? Applicant Purchased from others
b.
Were the confinement buildings designed by a professional engineer? Yes No
c.
Were the trusses designed and stamped by a professional engineer? Yes No
d.
Do trusses show any structural defects (bowed, missing plates, large cracks, etc.) Yes No
If yes, please explain in full detail:
e.
Were the buildings engineered for the appropriate wind zone, according to the International Building
Code wind speed map? Yes No
f.
What type of foundation/ wall construction does the building have?
Chain Wall Curb Wall WITH Solid End Doors Curb Wall WITHOUT Solid End Doors
Post in Ground WITH Concrete Footer Post in Ground WITHOUT Concrete Footer
Chain - combination of treated wood and reinforced concrete
Curb - reinforced concrete only
Post - treated wood only
g.
Do all confinement buildings have knee braces connecting each truss to each sidewall post?
Yes No
If Yes, what kind of knee braces exist?
Metal Wood
h.
Is the insulation covered with fire retardant material? Yes No
i.
What is the distance between buildings? (diagram available?)
j.
Are any of the confinement buildings connected by a common room or other structure?
Yes No
If yes, is there a firewall or minimum 2 hour Fire Barrier with a self-closing 1 ½ hour fire door at all
openings where the buildings connect? Yes No
k.
Were the buildings built for use as a confinement operation? Yes No
l.
Were the buildings built by a licensed contractor? Yes No
17.
Electrical
a.
What is the location of the control room for each confinement building?
End Middle No Control Room
Are the Breaker Boxes and Controllers located inside the grow out portion of the poultry house?
Yes No
b.
Is an electrical inspection done annually by a licensed electrician? Yes No
c.
Are all electrical panels properly grounded? Yes No
d.
Is the controller capable of remote contact with the applicant in case of emergency? Yes No
e.
Are the confinement buildings operated by a controller (computer)? Yes No
Page 5 of 6
Edition 4/1/2019
PSA-0419
PSA-0419
___
___
___
___
___
___
___
___
___
___
___
___
___
___
___
___
___
___
___
___
___
___
___
___
___
___
___
___
___
___
___
___
___
___
f.
Are there back up thermostats? Yes No
g.
Are controllers surge protected? Yes No
h.
Are electrical cords securely fastened away from fans? Yes No
i.
Are there adequate outlets to avoid multiple plugs and extension cords? Yes No
j.
Are circuit boxes fittings and electrical outlets properly maintained and covered? Yes No
**Fuse boxes are ineligible for coverage**
18.
Heaters
a.
Is there an incinerator on the premises? Yes No
If there is an incinerator in use, is it located at least 100 feet from the nearest building and does the
incinerator have a screen on top of it? Yes No
b.
Are heaters inspected regularly and serviced/replaced?
c.
What type of fuel is used in the confinement buildings?
d.
What type of heaters?
o
Wood Biofuel
Radiant Brooders Radiant Heaters Gas Fired Furnace Other:
e.
Are there any open flames? Yes No
f.
Do heaters have heat shields? Yes No
g.
Are heaters at least 12” from the ceiling? Yes No
h.
Are all flexible hoses used for gas supply lines to the heaters approved for use with LP and Natural Gas?
Yes No
i.
Are gas tanks located in a safe location? Yes No
*PLEASE BE ADVISED THAT AN INSPECTION WILL BE DONE ON ALL PREMISES WITH POULTRY HOUSES*
The undersigned is an authorized representative of the applicant and warrants and represents that commercially
reasonable efforts have been made to obtain true and correct answers to the questions in this document. The
undersigned further warrants and represents that the answers to the questions in this document are true, correct, and
complete based on such efforts. The undersigned understands and agrees that he/she will be held responsible for any
knowing misstatement or misrepresentation in the answers contained in this document.
Policyholder or Representative Date Insurance Agent Representative Date
Comments: (explanation of all no answers or undesirable features referenced by question number)
Yes N
LP NG
Page 6 of 6
Edition 4/1/2019
PSA-0419
PSA-0419
Download
Save PDF to desktop
Email
Email completed PDF
Send for Signing
Email for others to sign
Print
Print document
Choose a Field
Click on a field and
select the person that should complete it
Want to add a signature?
You can add a signature field
and assign it to someone else
to sign
Choose a Field
Click on a field and
select the person that should complete it

Form 1.: POULTRY SUPPLEMENTAL APPLICATION (James Allen Insurance)

This document is locked as it has been sent for signing.

You have successfully completed this document.

Other parties need to complete fields in the document. You will recieve an email notification when the document has been completed by all parties.

This document has been signed by all parties.

Completed 11 August 2021

Message

View Audit Log
Print With Audit Log
Duplicate Document