1. Applicant Information:
A. Full Name:
Mailing Address:
City: State: Zip Code:
Contact Name: Phone: E-mail Address:
Website Address:
B.
Individual Partnership Corporation Other:
C . Manufacturer Wholesaler Retailer Importer Exporter
D.
Number of years in business under current name?
Prior experience in this business under another name?
E.
Current affiliation with any other firms?
F.
Projected Sales and Receipts for the next policy term?
2. Products and Completed Operations:
Please use the following section to describe your products and services. Your description should include the following: those acquired via acquisition/merger, those planned for introduction in the next policy term, and those previously discontinued and date discontinued. Provide the number of year involved with each product; indicate which products you install, service or repair.
Attach brochures, catalogs, labels, instruction manuals, annual reports, D&B’s, Product Safety, etc.
Products/Services Years Principal End Install/Service/Repair % of Gross
Uses Annual
Sales
3. Claims History – 5 Years or more
A.
Total Aggregate losses, from first dollar up, including defense costs:
Policy
Term
Number of
Claims
Bodily
Injury
(Paid)
Property
Damage
(Paid)
Body Injury
(Reserve)
Property
Damage
(Reserve)
Total
Incurred
Total
Evaluated
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B.
Individual Losses, valued $5,000 or more from first dollar up including defense costs:
Date of
Occurrence
Product
Involved
Year
Manufactured
Describe
Occurrence and Injury or
Damage
Amount Paid and Reserved
C.
Are you aware of any other incidents, which may result in a claim against you?
If yes, give details:
Date Evaluated
4. Product and Sales Data
A.
For principal product or service, indicate:
Total Sales or
Receipts
Product or Service % of Total Sales Number of Units
Sold
Past 12 months
1 st prior year
2 nd prior year
Replacement Parts are what percentage of Total Sales?
B.
Do you import products or component parts?
C.
Do you export products or have foreign operations?
Yes No
Yes No
D.
Do you make or handle any product that is explosive, flammable or poisonous either by itself or in combination with other materials? Yes No
E.
Could any of your products be classified as:
Pharmaceuticals? Yes No
Cosmetics? Yes No
F.
Are any of your products sold under another’s name or label?
Yes No
G.
Do you purchase materials or components from others? Yes No
H.
Please explain all of the above “yes” answers:
5. Processing
A.
Do others assemble your products?
If assembled by others, do you supervise? as to installation?
B.
If installation by others, do you supervise or furnish instruction
Yes
Yes
Yes
No
No
No
If yes, please attach a copy.
If you maintain and service your products, attach a copy of your standard service contract.
6. Marketing
A.
Percentage of total sales to:
Wholesalers: Retailers: Consumers:
B.
Sales Territory:
If more than 15% of your goods or services are consumed in any one city, state or country, explain and
indicate percentage of total sales:
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C.
Suppliers and Distributors of your products.
Do you hold them harmless or insure them?
Do they hold you harmless or insure you?
If you answered Yes to either of these 2 questions, please explain:
Yes
Yes
No
No
7. Loss Prevention
A.
Have your products ever been subject to injury or investigation relative to product safety by any governmental agency?
If yes, attach details.
B.
Do you have a written products recall plan? If yes, please attach.
Yes No
C.
Have you ever recalled products because of a potential product safety hazard?
If yes, please attach details and indicate percent of recovery:
Yes No
D.
Has your management issued a written policy statement on product safety, which has been communicated to all employees? Yes No
If you answered with a “yes”, please attach.
E.
Do you have a written products safety program for which specific individuals have responsibility for implementation? Yes No
If you answered with a “yes”, please attach copy or outline.
8. Product Design
A.
Do you do your own design work?
B.
Do you maintain records of design changes and reasons justifying these changes?
C.
Are your designs subject to independent external review, testing or certification?
If “yes”, please attach details along with dates
D.
Are your products designed, tested, labeled and manufactured:
To meet or exceed all government and industry standards?
For optimum safety in spite of misuse or abuse?
9. Quality Control and Testing
A.
Are written testing procedures followed?
B.
Do you have a quality control manager responsible only to top management?
C.
Supplies and components:
Are they ordered to your specifications?
Have you determined which ones are critical to the safety of your final product?
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
No
No
No
No
No
No
No
No
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List those critical items, indicating whether testing is on a sample basis or on all units:
Are warranties obtained from all suppliers? Yes No
D.
Final Products:
Briefly describe tests applied before sale:
What percentage is tested? %
Are records of results of quality control tests kept so that you can identify at a later date what tests you applied to a given product at a given time? Yes No
How far back do your records go? (date)
10. Instructions/Warnings/Advertising/ Warranties
A.
Are hazards inherent in the final product and warnings against foreseeable misuse and abuse made known to the ultimate user by:
Warning labels at the point of hazard? Yes No
Yes No Written instructions?
Other means? If “yes”, attach details
B.
Do warning labels comply with federal statutory warning
Yes No labeling requirements? Yes No
C.
Are instructions, warnings, labels, and advertising texts subject to review, to assure that they are complete and understandable to the ultimate user, and to avoid overstatement relative to safety, or omissions relative to hazards by:
Legal counsel?
Top management?
Other? If “yes” attach details.
Yes No
Yes No
Yes No
D.
Do they expressly disclaim or limit warranties for your products?
E.
Are all warranties and/or disclaimers reviewed by legal counsel?
(submit copies of all warranties and disclaimers.)
F.
Do you provide any specific training or instructions for the
Yes
Yes
No
No ultimate user, in the proper use of your product?
If “yes” please describe:
Yes No
G.
Are salesmen and distributors made aware of your desire to be informed of cases where your postcard is used for a purpose for which it was designed? Yes No
11. Loss control and Defense
A.
Explain how you can identify your products and parts from similar competitors’ products and parts:
B.
Can you determine, based on available records, for all products you have sold:
When any given product was manufactured?
To whom it was sold, and the dates of sale?
Who supplied parts and supplies going into the final product?
Yes No
Yes No
Yes No
C.
Do you maintain copies of old instruction or operation manuals and advertising material? Yes No
D.
Accident Exposure:
Do you have a written procedure for obtaining information about product complaints, accidents and injuries involving your products? Yes No
Have you made distributors aware of your desire for prompt notice of all complaints, accidents and injuries involving your products? Yes No
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Does your procedure provide for examining and preserving any allegedly defective product, with the results of such examination recorded? Yes No
Do reports on complaints, accidents, injuries and examination of products involved, go to:
The person responsible for product safety? Yes No
Top management? Yes No
12. Current Program
A.
Limits: $
B.
SIR/Deductible: $
C.
Rate: $
D.
Insurer:
E . Has any insurer ever canceled, restricted or refused to renew your products liability insurance? If “yes”, please attach details. Yes No
13. Insurance requested
A.
Limits desired: $
B.
SIR desired: $
14. 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:
Title:
Date:
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:
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