FOOD PRODUCTS SUPPLEMENT

Copyright, 2021 Selective Insurance Company of America. All rights reserved. MW 1006 06 21 of 7

WHOLESALERS QUESTIONNAIRE Complete, answer, or check () for “Yes,” where appropriate.

ACCOUNT INFORMATION Business Name:

Business description:

Website(s): Email Address:

Year business started: Years of management experience in this business:

Describe operations or product lines started in last 3 years:

Describe discontinued operations or products:

Have you filed for bankruptcy within the past 5 years? Yes No

PROPERTY & PROTECTION Hours of operation:

Was the building built for your occupancy? Yes No How long at location?

Does the property have full sprinkler protection? Yes No

If No, provide % covered and describe areas not protected and the square footage:

If Yes, answer the following:

Is the sprinkler system hooked to a central station? Yes No

Is there an ESFR sprinkler system? Yes No

Are there in-rack sprinklers? Yes No

Is there a fire or booster pump for sprinklers? Yes No

Do you have a sprinkler maintenance contract? Yes No Date of last service:

Does your business have:

1. Freezers? Yes No If Yes:

Are freezers fully sprinklered inside? Yes NoIs a program in place to prevent ice plugs in sprinkler piping? Yes No

2. Refrigerators? Yes No If Yes:

Refrigerator area: square feet

Are units fully sprinklered inside? Yes No

Is the building fully protected with central station smoke or heat detection? Yes No

If partial, describe areas covered:

Is there a central station burglar alarm? Yes No


Are there any flammable or combustible liquids stored? Yes No

If Yes describe what and how much:

Are there aerosol can products stored? Yes No

If Yes, what is the quantity and is there any special storage arrangement:

What is the height of warehouse storage? ft Describe the storage arrangement:

CONTINGENCY PLANS Do you have a formal business interruption contingency plan? Yes No

For accounts with refrigerators or freezers: If None, skip to the next section. Are there low temperature alarms? Yes No

Are there back-up generators on-site? Yes No N/A

If Yes, answer the following:

Do they cover all freezers and refrigerators? Yes No

Fuel used:

How often are they tested?

Are there signed contracts with a generator rental company in the event of a power failure? Yes No N/A

Can reefer vehicles in fleet be used to back up storage unit in a power failure? Yes No N/A

GENERAL LIABILITY Any Retail Sales? Yes No If Yes, what are the total retail sales from your locations?

Any Premises outside U.S. operated by you? Yes No Describe:

Any installation, service or repair operations? Yes No Describe:

Any work subcontracted to others? Yes No Amount: $ Describe:

PRODUCTS: Total Gross Sales: $ Internet Receipts: $ International Receipts: $

Receipts breakdown (describe type goods and sales for each category of sales): Durable Goods (Ex: Hardware, Machinery) Non-durable Goods (Ex: Foods, Paper products)

Goods: $ Goods: $

Goods: $ Goods: $

Goods: $ Goods: $

Goods: $ Goods: $

Goods: $ Goods: $

Goods: $ Goods: $


Do you import any goods directly? Yes No If Yes, what are receipts? $

Describe:

Are any goods sold under your business label? Yes No If Yes, Describe:

If Yes, describe who designed or developed the product specifications, and who manufacturers:

Are goods of others modified or repackaged by your business? Yes No If Yes, describe:

Do you own any patents or product trademarks? Yes No If Yes, describe:

Do your suppliers provide you with any contractual indemnification or vendor’s coverage? Yes No

If Yes, describe:

Any new product lines planned? Yes No If Yes, describe:

LIQUOR LIABILITY (Beverage Distributors Only) Liquor Liability coverage requested? Yes No ABC License No. Type of License held: (wholesale, retail, etc.) License ever: Revoked Rejected Please provide details:

Are draft trucks rented? Yes No If Yes, How many? Receipts: $

(Attach copy of agreement) If above is Yes, who provides servers?

QUALITY CONTROLS How long are records kept on product sales? years

Are all product batches traceable? Yes No

Are rejected products destroyed? Yes No If No, describe:

Is the “sold by/use by” date on products adhered to? Yes No N/A If No, describe:

Any products recalled in last 10 years? Yes No If Yes, describe each event:

For any machinery modified or re-built:

Are photos or videos taken to confirm the existence of machine guards? Yes No N/A

Are warning labels in place? Yes No N/A

Are the photos or videos retained as a permanent part of the file for the machine? Yes No N/A Is there a formal program for product recalls? Yes No


Has your business ever been shut down by a governmental authority? Yes No If Yes, describe:

Has your business ever fined or penalized by a governmental authority? Yes No If Yes, describe:

AUTOMOBILE Drivers

Total number of Drivers that are: Employees: Owner/Operators: Leased:

Temporary:

How many of each have been hired in the last 12 months? Employees: Owner/Operators:

Leased: Temporary:

Hiring practices include: Check all that apply:

Written applications Pre-hire Physical Drug Testing

Pre-Hire MVR Reference Checks Written MVR Criteria

Interview Driving Test Written Test

New hire orientation training includes: Check all that apply:

Route Familiarity Equipment Accident Reporting Procedures

Load Handling Company Rules

Are MVRs ordered for all drivers? Yes No If Yes, how frequently?

Are driver files maintained in accordance with Federal Motor Carrier Safety Regulations? Yes No

Owner/Operators

Are owner/operators used? Yes No If No, skip to next section.

If Yes, are they exclusive? Yes No (Provide a copy of the Owner/Operator contract) Are owner/operators permanently leased? Yes No

Are permanently leased operator units included on the vehicle schedule? Yes No

If not covered under this policy is proof of insurance is required? Check those that apply:

Truckers Liability coverage required? Non-Trucking liability coverage required?

Bobtail only coverage required? Liability limits at least equal to requested policy limits?

Are owner/operators subject to same hiring procedures as employee drivers? Yes No

Auto Operations

Do you only transport your own goods? Yes No

If No, what percent of total goods and receipts transported is for others? % Receipts

Are these only backhauled goods? Yes No

What types of goods are hauled for others?

Number of Power Units: Current Year: Prior Year:

Are all non-owner operator vehicles on this policy registered in the company name? Yes No


Percentage of trips that are:

0-50 miles: % 51-200 miles: % 200+ miles: %

What major cities will you pass through on intermediate/long haul trips?

1. 3. 5.

2. 4. 6. Do you operate/travel into Canada or Mexico? Yes No

Are prescribed routes used? Yes No

Are all owned and long-term leased vehicles included on schedule? Yes No

Are trucks/tractors rented (without operators) on short term basis for your use? Yes No

Estimated cost of hire for the coming year: $

Are Motor Carrier Filings required? Yes No Check those that apply:

FMSCA State DOT MCS-90 Other: Describe:

DOT#/Docket#? Yes No If Yes, list below:

DOT #: ____________ MC #: FF#: MX#:

Any Transportation of Hazardous Materials requiring placarding? Yes No If Yes, please describe and provide

total % of receipts this represents: Any “expedited” or time-sensitive hauling? Yes No

Refrigerated units used in your operation? Yes No

If Yes, how often is preventative maintenance performed on the units? Is maintenance out-sourced? Yes No

If Yes, who performs maintenance?

Do any of the following apply?

Pull double trailers? Dump trucks/ trailers or roll-offs?

Tanker truckers/trailers? Oversize loads requiring special permits?

Elongated trailers or flatbeds used? Bobtail (tractor without trailer)?

Deadheading (tractor with empty trailer)?

Do employees use their own personal vehicles for business purposes? Yes No If Yes, describe:

If Yes, are they required to provide evidence of personal insurance at an acceptable limit? Yes No

Vehicle Maintenance/Safety

Are theft deterrent systems in place on both tractors and trailers? Yes No

Are pre/post trip inspections made daily? Yes No

Is there a written vehicle maintenance program? Yes No

Who provides vehicle service? Please describe:


How long are vehicle maintenance records kept?

What is your tire replacement policy?

Are retread tires used? Yes No If Yes, please describe:

Do you have a formal auto safety program? Yes No If Yes, please describe:

Do you have a safety manager on staff? Yes No If Yes, provide name:

Is there a safety award program? Yes No If Yes, describe:

Is there a progressive discipline policy to address accidents and driving infractions? Yes No If Yes, please

describe: ________________________________________________________________________________________

Are speed governors used on your trucks? Yes No

Do you have an accident investigation program with follow-up? Yes No If Yes, please describe:

Do you use SafetyFirst or any other 1-800 How’s My Driving service? Yes No

Do you use GPS/vehicle tracking or other technology to monitor driver behavior and help identify training needs?

Yes No If Yes, please describe:

Additional Information Required Please attach the following additional information:

• Complete list of vehicle operators (employees, owner/operators and long term leased) including driver’slicense numbers, dates of birth, and year hired.

• Copies of all types of owner/operator agreements/contracts you use.• 4 years of currently valued loss runs from the prior carrier.• IFTAs for the last 4 quarters if applicable.

EEO & EO PRACTICES/PROCEEDINGS

1. Do you have non-discriminatory hiring practices that prohibit exclusion based on race,color, religion, sex, sexual orientation, national origin, disability, or age? Yes No

2. If a membership organization, do you have a non-discriminatory membership policythat prohibits exclusion based on race, color, religion, sex, sexual orientation, nationalorigin, disability, or age? Yes No

3. Has the company been involved in or experienced during the past three years, or arethere now pending, any proceedings before:

a. The Equal Employment Opportunity Commission Yes Nob. The State Human Rights Commission/Department Yes Noc. The State Ethics Commission; or Yes Nod. Similar administrative, regulatory; compliance-office? Yes No

If ‘Yes’ to any of the above please provide detail.


4. Has any adverse judgment or settlement been brought against the insured organization whereby part of the settlement included employee and/or management sensitivity training, diversity training, sexual harassment training and/or discrimination training in the past three years? Yes No

If ‘Yes’ to the above please provide detail.

5. Do you allow employees to carry weapons on premises or the jobsite? Yes No

FOOD PRODUCTS SUPPLEMENT

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