Supplemental Application for Products and
Completed Operations Liability Insurance
Steadfast Insurance Company
Dover, Delaware
Administrative Offices: 1400 American Lane,
Schaumburg, Illinois 60196-1056
A. Applicant
Full name
Principal address
B. Product and Sales Data
1. For principal product or service, indicate:
Descriptions of Major Products
# of Units
Sold
PRINCIPAL END USES
REPLACEMENT PARTS are what percentage of total sales?
Manufacture
or Distribute
% OF GROSS
ANNUAL SALES
%
C. Manufacturing/Distribution
Yes
No
Does the applicant import products or component parts?
If so, what percent?
Does the applicant's supplier provide the applicant with US insurance?
Does the applicant export products or have foreign operations?
Could any of the applicant's products or services be used on or in connection with:
aircraft/missile/aerospace?
watercraft or offshore?
transportation/pollution/waste treatment?
Does the applicant make or handle any product that is explosive, flammable or poisonous either
by itself or in combination with other materials?
Could any of the applicant's products be classified as:
pharmaceuticals?
cosmetics?
Are any of applicant's products sold under another’s name or label?
Does applicant purchase materials or components from others?
Does applicant install, service or demonstrate products?
If installation by others, does the applicant supervise or furnish instructions as to installation?
Does applicant have exhibits at trade shows, conventions, etc?
If the applicant want to learn more about the compensation Zurich pays agents and brokers visit: http://www.zurichnaproducercompensation.com or call the
following toll-free number: (866) 903-1192. This Notice is provided on behalf of Zurich American Insurance Company and its underwriting subsidiaries.
STF-SC-123-B CW (02/08)
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Does applicant conduct public tours more than 4 times a year?
Are temporary workers used for more than 10% of the applicant's workforce?
Are any products rented or leased to others by the applicant?
Are the applicants products stand alone or final?
Are the applicant's products components in another product?
Does the applicant use subcontractors for any production processing?
D. Marketing
Percentage of total sales to: Wholesalers:
% Retailers:
% Consumers:
Suppliers Does the applicant hold them harmless or insure them?
Do they hold the applicant harmless or insure the applicant?
%
YES
NO
YES
NO
YES
NO
YES
NO
Distributors –
Does the applicant hold them harmless or insure them?
Do they hold the applicant harmless or insure the applicant?
E. Loss Prevention
Have the applicant's products ever been subject to injury or investigation relative to product
safety by any governmental agency? If “yes”, attach details.
Does the applicant have a written products recall plan? If “yes”, please attach.
Has the applicant ever recalled products because of a potential product safety hazard?
If yes, attach details and indicate percent of recovery:
%
Does the applicant have a written products safety program for which specific individuals have
responsibility for implementation?
If “yes” attach copy or outline.
F. Product Design
Does the applicant do their own design work?
Does the applicant maintain records of design changes and reasons justifying these changes?
Are the applicants designs subject to independent external review, testing or certification?
If “yes” attach details and dates
Are the applicant's products designed, tested, labeled and manufactured to meet or exceed all
government and industry standards?
G. Quality Control and Testing
Are warranties obtained from all suppliers?
Are records of results of quality control tests kept so that the applicant can identify at a later
date what tests the applicant applied to a given product at a given time?
Does the applicant have a full-time Quality Control Manager?
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H. Instructions/Warnings/Advertising/Warranties
YES
NO
YES
NO
Do warning labels comply with federal statutory warning labeling requirements?
Does the applicant expressly disclaim or limit warranties for their own products?
Does the applicant provide any specific training or instruction for the ultimate user, in the proper use
of the applicant's product?
If “yes”, please describe:
I.
Loss Control and Defense
Can the applicant determine, based on available records, for all products the applicant have sold:
When any given product was manufactured?
To whom it was sold, and the date of sale?
Who supplied parts and supplies going into the final product?
Does the applicant maintain copies of old instruction or operation manuals and advertising
material?
Accident procedure:
Does the applicant have a written procedure for obtaining information about product
complaints, accidents and injuries involving the applicant's products?
Does the applicant's procedure provide for examining and preserving any allegedly
defective product, with the results of such examination recorded?
Do reports on complaints, accidents, injuries and the examination of products involved, go
to:
(1) The person responsible for product safety?
(2) Top management?
Are visitors accompanied on-site?
Warranty
I/We warrant that the information contained herein is true and that it shall be the basis of the policy of insurance and
deemed incorporated therein, should the Company evidence its acceptance of this application by issuance of a policy.
Signature of applicant: ____________________________________ Date: __________________________________
Title: ________________________________________________ (owner, partner, officer)
* Signing this form does not bind the applicant or the company to complete the insurance. Application must be signed
by the applicant and dated to be considered for quotation.
SUBMITTED BY:
Producer:
Address:
City:
State:
Zip Code:
STF-SC-123-B CW (02/08)
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