Fillable Pork Producers Confinement Operation Questionnaire (Risk Placement Services, Inc.)

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Pork Producers Confinement Operation Questionnaire (Risk Placement Services, Inc.)

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Pork Producers Confinement Operation
Questionnaire
Agency:
Insured:
Date:
Policy Number:
General Information
1. Description of Operations (Feeder Pigs, Farrow to Finish, Finish Only, etc) __________
__________________________________________________________________________
__________________________________________________________________________
2. Other Farming Operations ___________________________________________________
__________________________________________________________________________
3. Years of Hog Confinement Management Experience _____________________________
4. Describe Present Safety Program ____________________________________________
__________________________________________________________________________
__________________________________________________________________________
5. Is there a person on the premises at all times? Yes No If No, describe
controls in place to mitigate a loss ___________________________________________
__________________________________________________________________________
__________________________________________________________________________
6. Describe any losses occurring in the past five years ____________________________
__________________________________________________________________________
__________________________________________________________________________
7. How does management handle losses? (i.e. – loss review, implementation of new loss
prevention activities, etc.) ___________________________________________________
__________________________________________________________________________
__________________________________________________________________________
Attachments:
Photographs of each building
Diagram of each location, including distances between each building
Building Valuation for each building
Signatures:
Producer: ______________________________________ Applicant: _____________________________________
Edition 09-2003
1
click to sign
signature
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Pork Producers Confinement Operation Questionnaire
Property Information (Complete this section for each confinement building used by the insured)
1. Who designed and built the facility? __________________________________________
2. A. Age of the Building _______
B. Age of Roof _______
C. Age of Electrical, HVAC & Plumbing _______
3. Is a written housekeeping program in place for this building? Yes No
4. Is there a scheduled maintenance plan in place for this building? Yes No
5. What type of fire protection is available? ______________________________________
__________________________________________________________________________
6. Lightning protection? Yes No
7. Smoking restricted in and around the building? Yes No
8. Wiring in conduit? Yes No
9. Roofing material? ______________ If Metal, what gauge? _________
Wind uplift rating? ______________
10. Security system? (Alarms and how they operate
A. Alarms? Yes No If Yes, how do they operate? _____________________
_______________________________________________________________________
B. Does the manager reside on the premises? Yes No
C. Is the property fenced? Yes No
11. Is this building connected to any other buildings? Yes No If Yes, are there
fire doors? Yes No, and are they kept closed at all times? Yes No
12. Does this building have an automatic drop curtain system in the event of an
interruption of power? Yes No
13. Is there auxiliary power generating equipment sufficient to operate the equipment that
controls the movement of air, temperature, and atmosphere within the building?
Yes No If Yes, describe _____________________________________________
__________________________________________________________________________
__________________________________________________________________________
14. Is the auxiliary power in good working condition? Yes No
15. Is there an alarm system that signals interruption of power to the building? Yes No
If Yes, does that alarm system have a rollover telephone number feature in the event the
primary contact does not respond? Yes No If Yes, how many numbers is the
system programmed to rollover to? __________
16. Does the auxiliary power generating equipment function automatically upon the
interruption of power supplied by the normal source of power? Yes No
17. Is the auxiliary power generating equipment tested at least once per month and is a log
kept of the date tested and the person who tested it? Yes No
Edition 09-2003
2
Pork Producers Confinement Operation Questionnaire
Property Information (continued)
18. Livestock breakdown:
Number Total Estimated Value
Boars
Sows/Gilts
Shoats/Market Hogs
Pigs
19. Coverage desired on Livestock - Basic C.O.L.
Broad C.O.L.
Named Perils including Smothering,
Asphyxiation, or Suffocation
No Coverage
Note: The Protective Safeguards Endorsement is mandatory when we use the coverage
form providing named perils including smothering, asphyxiation, or suffocation.
Edition 09-2003
3
Pork Producers Confinement Operation Questionnaire
Liability Information
1. Who has access to the facility besides the insured and their employees? ___________
__________________________________________________________________________
2. What are the adjacent structures, if any, and distance of separation? ______________
__________________________________________________________________________
__________________________________________________________________________
3. How is the animal waste managed (manure pits vs. septic lagoons)? _______________
4. Does the insured contract with a waste removal contractor or do they recycle the
waste on the farm premises? ________________________________________________
5. Does the insured involve an environmental consultant to monitor the lagoon and/or
soil quality and condition? Yes No If Yes, describe the frequency and the
extent of the involvement. ___________________________________________________
__________________________________________________________________________
6. Describe any business operations other than the confinement operations. __________
__________________________________________________________________________
7. Does the insured use subcontractors? Yes No If Yes, are Certificates of
Insurance obtained from the subcontractors? Yes No What Limits of Liability
are require, by the insured, from the subcontractors? ___________________________
Edition 09-2003
4
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Completed 30 July 2020

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