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POULTRY SUPPLEMENTAL APPLICATION (Risk Placement Services, Inc.)

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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: _____________ Expiration Date:___________ Expiring Premium:________
2. Losses in past 5 years? ___ Yes ___ No
3. If yes, please describe in full detail: _______________________________________________________________
*** (Three(3) year hard copy loss runs are required to bind coverage) ***
4. Ho
w 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. Na
me 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. Build
ing(s) are ___ Occupied or ___ Vacant?
If there are any vacant buildings are we being requested to insure them? ___ Yes ___ No
10. Wh
at is the type of confinement operation? ___ Commercial Eggs ___ Pullets ___ Breeder Hen ___ Broiler
11. Fin
ancial 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. _________________________________________
12. Hav
e 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
Edition 4/14/2015
1
d. Is there 24 hour on-site security (someone lives on premise full-time)? ___ Yes ___ No
e. Is there a spontaneous combustion prevention program in place? ___ Yes ___ No
f.
How do you dispose of your birds? _________________________________________
i.
If composting is there a spontaneous combustion prevention program in place? ___ Yes ___ No
g.
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
b. Is the generator tested “under load” weekly? ___ Yes ___ No
c. Is the generator weather protected and well ventilated? ___ Yes ___ No
d. Is the generator in a separate unconnected building? ___ Yes ___ 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
Edition 4/14/2015
2
15. Construction
Building
1
2
3
4
5
6
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
Edition 4/14/2015
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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
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**
Edition 4/14/2015
4
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? ___ Yes ___ No
c. What type of fuel is used in the confinement buildings? ___ LP ___ NG ___ Wood ___ Biofuel
d. What type of heaters?
___ 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
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)
___________________________________________________________________________________________
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Edition 4/14/2015
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Completed 30 July 2020

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