PRODUCTS LIABILITY PROPOSAL FORM
Please note that you are under a duty to disclose all facts likely to influence the acceptance assessment
of your proposal. Failure to do so may prejudice the settlement of any claim. Please mention such facts,
or if you are in any doubt refer to the Company.
To Yes/No answers please tick the applicable questions. Please answer all questions, Failure to do so
may mean that no quotation will be given. If there is insufficient space for a complete answer to any
question, please continue on an additional sheet of paper.
GENERAL INFORMATION
1.a.
Name of Applicant (include all Subsidiary Companies)
1.b
Address of Applicant:
2.
Please indicate the Applicant's requirements in respect of the following:
a. Limit of Indemnity
c. Retroactive Date
3.
4.
5.
b. Deductible
d. Discovery Period
Applicant is:
an Individual
a Joint Venture
a Partnership
Other (please specify)
a Corporation
Business of Applicant:
Manufacturer
Retailer
Distributor
Other (please specify)
Importer/Exporter
Does the applicant have any representation or assets in the US/Canada? Yes/No
If Yes, please give name(s) and addresses and indicate the nature of representation and/or
assets
6.a.
How long has the Applicant been in business?
6.b.
Has the applicant assumed any liabilities upon the acquisitions of any new entities within the
last 5 years? Yes/No
6.c.
Has the applicant sold or ceased operating any companies (both under the present name and
any previous name) within the last 5 years for which indemnity is still required? Yes/No
If Yes to either 6b or 6c please provide, on a separate sheet, full details including a list of the
products involved and estimated figures.
PRODUCT DETAILS
7.
List the turnover figures for the past 5 years as well as the estimated turnover for the
forthcoming year. Indicate the approximate percentage split in turnover per territory.
Year
8.
Turnover %
USA/Can. %
Japan
Australia
Europe %
Others %
List all products manufactured, sold, supplied, distributed or exported by the applicant
worldwide during the last 5 years and specify their uses. Please indicate the approximate
percentage of overall turnover for the forthcoming year relating to each product and the
number of anticipated units.
Product
9.
Currency %
Use
% Of turnover
USA/Canada
Number
of units
Are any of the applicant's products:
a. Used as a component for other products?
b. Manufactured by the applicant to the
specification of the customer?
c. Explosive, flammable or toxic either by itself
Or when combined with other materials?
d. Pharmaceuticals and/or cosmetics?
e. Components for, or used on, or with any
aircraft, missile, water craft or offshore operations
or used in the transportation, transit or life
support services?
f. designed by others?
Yes/No
Yes/No
Yes/No
Yes/No
Yes/No
Yes/No
If Yes to any part of question 9, please give full details:
10.
Who assembles the products?
The manufacturer
The Importer/Exporter
The consumer
Yes/No
Yes/No
Yes/No
11.a.
Have any new products been introduced in the last 5 years or are any new products anticipated
in the next 12 months? Yes/No
11.b.
If yes, are any of these products intended for sale within the USA/Canada? Yes/No
If yes, to either part of question 11, please give full details.
PRACTICES AND PRODCEDURES
12.a.
Is a written products liability loss control programme in effect? Yes/No
12.b.
Do the products conform with the National Safety Standards applicable to the countries in
which they are manufactured, sold, distributed or exported to? Yes/No
12.c.
Does the applicant employed the services of a testing laboratory?
If yes, what products are tested?
12.d.
Has any product ever been subject to inquiry or investigation relative to product safety or
breach of legislation by any government or regional agency or department? Yes/No
If yes answered to any part of question 12, please give full details:
13.a.
Please describe the applicant's quality control procedures:
13.b.
Please give details of how the applicant would identify any particular batch of products and
distinguish their products/components from other similar products/components?
13.c.
What methods of record keeping are in force in respect of the applicants products and how
long are such records kept?
13.d.
Is there a product Recall Plan in force?
Yes/No
If yes, please give details, including how often the plan is updated and tested
14.a.
Please give details of any warnings, warranties or disclaimers supplied with or on the
applicant's products or product literature or within their advertising and state whether written
in the language of the country the products are sold in
14.b.
Does the applicant retain rights of recourse against the manufacturer of any products or
components supplied to them?
VENDORS INFORMATION
15.
If an indemnity for vendors is required, please list any existing any existing vendors to be
included. This list should include the following:
a) full name and address of each vendor
b) which of the insured's product(s) each vendor sells.
c) how long each vendor has been selling the applicants products.
d) estimated forthcoming turnover expected in respect of each vendor.
Name
Address
No.
Years
Products
Turnover
Retro Date
Please note: If submitted for renewal, the existing retroactive dates will be retained unless
otherwise advised by the Insured.
VENDORS INFORMATION
16.
What current provisions exist for the notification of incidents from the vendor to the
applicant?
Please Note:
All the above mentioned vendors will attach to the limited vendors clause. All
changes to the above list must be advised to the insurers immediately. All new
vendors will be held covered for one months pending receipt of satisfactory
information requested in Appendix I.
CLAIMS RECORD
17. Please list details of all claims made against the applicant during the last 5 years, including those
against any proposed vendors. Such details must include amounts within any past or proposed
deductibles, all defence and show whether paid or outstanding
Year
No. of
Claims
Total amount incurred in
US/Canada
Bodily Injury
Property
Damage
Total amount incurred
elsewhere
Bodily Injury
Property
Damage
Please Note: If no claims in any particular year, write "None".
18.
Please describe all claims listed above and state whether paid or outstanding:
Date of
Occurrence
19.
Date of
Claim
Product
Description of
Loss
Amount Paid or
Outstanding
Is the applicant aware of any other incidents which may result in a claim against them or of
any product which because of known defects or inherent hazards, is likely to cause bodily
injury or property damage?
Yes/No
If yes, please give details:
20.
Please advise and give reasons for any product that has been discontinued or recalled in the
last 5 years or any product the applicant is considering discontinuing
21.a.
Who is the current insurer?
21.b.
Has any insurer ever cancelled or refused to renew any insurance policy in respect of the
applicant or imposed special restrictions?
Yes/No
If yes, please give details:
Please attach any products brochures/instructions/manuals, product safety surveys and any other
information relating to the applicant's products.
Do not sign the declaration below until you have read and understood it
I/We declare that to the best of my/our knowledge and belief all the statements and particulars made
with regard to this proposal are true and I/We agree that this proposal shall be the basis of a contract of
insurance to be expressed in the terms of the policy between the applicant and the company.
Applicant's signature
Applicant's title:
Date: