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PREMISES 2. How many miles distant is the (Risk Placement Services, Inc.)

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DAIRY ADDITIONAL INFORMATION REQUEST
CP-7549 10 11 Copyright 2011 The Travelers Indemnity Company Page 1 of 3
Insured & policy #: ___________________________ Agent: ________________ Date: ____________
Customer website: ____________________________________________
PREMISES
1. Is there someone on the premises 24/7? Yes _____ No ______
If yes, who and comment if they live on the premises? ________________________________________
Dairy manager # years experience: _________
2. How many miles distant is the nearest community or habitational subdivision from the dairy & lagoon?
__________________. Does the insured carry pollution coverage: Yes ____ No ____
3. Has the insured ever been a party to any litigation involving odor or pollution? Yes____ No _____
4. Is the dairy open to the public including tours? Yes ___ No ____
If yes, how often?__________ To whom? _________________
Please list all safety measures taken regarding visitors including visitor check in/out, requirements all visitors
be accompanied by a dairy employee at all times and posting of warning signs: _______________________
_______________________________________________________________________________________
5. Who hauls milk away from the dairy? _________________________________________________________
(If by a contract carrier provide copy of cert. for each)
6. Do the dairy parlors have lighted exit signs? Yes ____ No ___
Slip & fall mats present? Yes ____ No ______
Does the dairy have alarms: Yes ___ No ___ Where/type: _______________________________________
Where are fire extinguishers kept? __________________________________________________________
How often are they checked? ______________________________________________________________
Does the insured have a smoking policy? Yes____ No___
If yes please describe and indicate where the policy is posted? ____________________________________
7. Does the insured have auxiliary generators as a backup source with sufficient horsepower to sustain dairy
operations? Yes ____ No _____. How often are the generators tested? ____________________________
8. How and where are agricultural chemicals stored? ______________________________________________
EMPLOYEES
1. Does the insured have a formal workplace safety program? Yes ____ No ____
Does the insured have a driver safety program? Yes ____ No ____
How are programs enforced? _______________________________________________________________
2. Are vehicles provided for personal use to employees? Yes ____ No ____. Which employees (list names)?
_______________________________________________________________________________________
_______________________________________________________________________________________
Who orders MVRs? ____________________ How often? _______________________________________
3. Are employees trained in firefighting techniques? _______________________________________________
4. Has an employee been injured while employed on the dairy? Yes ____ No ____. Provide details of
loss/losses: _____________________________________________________________________________
_______________________________________________________________________________________
CP-7549 10 11 Copyright 2011 The Travelers Indemnity Company Page 2 of 3
5. If employees live on the dairy premises, describe safety measures taken to protect children and to limit their
access to livestock, lagoon, hay, equipment, etc.: _______________________________________________
_______________________________________________________________________________________
6. Are resident employees required to obtain their own insurance (HO4, auto)? Yes ____ No ____
Insured & policy #: _______________________________ Agent: _________________________________
HAY
1. How many hay brokers has the dairy used in the past 24 months? __________________________________
Is hay stored at broker locations? Yes ____ No ____
2. Who is responsible for accepting and checking hay deliveries? ____________________________________
What procedures are used to monitor moisture in hay and how often are they used?
_______________________________________________________________________________________
_______________________________________________________________________________________
Are any alarms/fire protection used for hay? Yes ____ No ____
3. What is the maximum value ($) and tonnage of hay in any one barn? ________________________________
Are all hay barns/stacks at least 100 ft. apart? _______ (submit diagrams showing distance between
buildings).
HERD AND PRODUCT MANAGEMENT
1. Does the dairy keep detailed records regarding cattle purchases and sales? Yes ____ No ____
2. Does the insured purchase grain or feed supplements from outside the continental U.S.? Yes ____ No ____
3. What controls are in place to keep feed from being contaminated? _________________________________
4. Have there been ANY regulatory violations in the last 5 years? Yes ____ No ____
If yes, please describe: ____________________________________________________________________
_______________________________________________________________________________________
5. How often is the herd vet checked for health issues? ____________________________________________
6. Describe in detail the segregation program for medicated animals:__________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
7. Does the insured sell sick downer cows for slaughter? Yes ____ No ____
8. Does the insured have a formal contingency plan to ensure the cows will continue to be milked if there is a
loss to the milking parlor? Yes_____ (please provide copy) No _____
9. Is milk tested prior to being loaded into a tank truck? Yes ____ No ____
By whom? _____________________________________________________________________________
10. Has there ever been a milk contamination or pollution incident? Yes___ No ___ If yes, list the dates of each
occurrence and describe what has been done to prevent future incidents: ____________________________
_______________________________________________________________________________________
CP-7549 10 11 Copyright 2011 The Travelers Indemnity Company Page 3 of 3
11. Describe any sales of milk or milk products, or any processing, other than milk sold to the co-op/creamery:
_______________________________________________________________________________________
12. Are there any products under the insured’s label? Yes ___ No____. If Yes, what is label name?
_______________________________________________________________________________________
13. Is milk sold on premises? Yes _____ No ____
14. Does the insured sell "raw milk" (unpasteurized) direct to the public? Yes ____ No ____
15. Total number of head being milked: ___________________ Total herd: ____________________
Average milk production on daily basis? _______________________________________________________
Collapse:
Has any building experienced a partial or total loss in the last 5 years? Yes ____ No ____
If yes, please provide details/building type ________________________________________________
Have you observed the following on ANY building listed on the policy? If yes, describe building & location.
1. Sagging roof steel or visibly deformed rafters? Yes ____ No ____
2. Cracked or split wood members? Yes ____ No ____
3. Doors that pop open? Yes ____ No ____. Doors or Windows are difficult to open? Yes ____ No ____
4. Bowed utility pipes or conduit at ceiling? Yes ____ No ____
5. Creaking, cracking or popping sounds? Yes ____ No ____
6. Please describe snow removal plan including any vendors used to perform service:
_______________________________________________________________________________________
7. What equipment is hung from the trusses? ____________________________________________________
How many? ________________ How much does it weigh? _________________________________
Was truss designed to handle this load? Yes ____ No ____
SIGNATURES
Insured Signature: ____________________________________ Date: _________________
Print Insured Name: ___________________________________
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Completed 30 July 2020

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