York Jersey Underwriters Agency Inc.

Applicant's Instructions:

Answer all questions completely. Application must be signed and dated by owner, partner, or officer not earlier than 45 days before proposed effective date of coverage.
Please read the statements at the end of this application carefully. Thank you.
Make sure you complete all fields before submitting. Click on Submit when ready to send.

Applicant Name:*

Title:*

Company Name:*

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Email Address:*

example@example.com

Date:*

1. Give the full name of the applicant and subsidiary companies and operations of each:*

2. Principal Address:*

3. Website Address*

4. Type of business:

Corporation:Partnership:Proprietorship:

Other: (Please specify)

5. Sales/Receipts estimate for the next 12 months:

USA & CANADA: $*

REST OF THE WORLD: $*

5a. Please list the countries you are selling to other than the USA & Canada:*

6. Limits of liability required: $*

6a. What day would you like the policy effective?*

7. How many years has applicant been in business under the current name?:*

8. Have any of the principals ever engaged in this or similar enterprises under a different name?:*

YesNo

9. Please state the name, title and telephone number of the person we may contact in order to arrange for an inspection of your operation:

Name:*

Title:*

Telephone #:*

PRODUCTS AND SERVICES

10. Describe the products and services of the applicant and show the number of years each product or service has been offered:*

11. Who performs the installation of the applicant's product(s)?:

ApplicantCustomerThird Party hired by ApplicantThird Party hired by Customer

(if more than one method used, please explain)

12. What products have you ceased manufacturing during the past ten (10) years?: Provide details or state "none" if none applies.*

13. Does applicant retain the liability for any products or operations which they no longer control?:*

YesNo

(if yes, provide details)

14a. Have any products been acquired by merger or acquisition?*

YesNo

(if yes, provide details)

14b. Did the applicant assume liability of these products?:*

YesNo

(if yes, provide details)

15. Sales in the last three years:*

	U.S.	Canada	Rest of World
Sales Estimate:
First prior year:
Second prior year:
Third prior year:
Fourth prior year:
Fifth prior year:

	Product Description	Years in Market	Estimated Product Life	% of Gross Sales M / W / R I / MR	Products Sold To M / W / R I / C / O	Does Applicant (I) Install or (R) Repair
1
2
3
4
5
6

M = Manufacturer R = Retailer MR = Manufacturer Rep. O = Other
W = Wholesaler I = Importer C = Consumer - direct

16. Will any new products be introduced in the new 12 months?:*

YesNo

(If yes, please explain)

17. Do you import products or component parts?:*

YesNo

(If yes, please explain)

18. Have you ever recalled products?*

YesNo

(If yes, please explain)

19. Have any of your products ever been subject to injury or investigation relative to product safety by a governmental agency?:*

YesNo

(If yes, please explain)

20. How can your products be identified from the products of your competitors?:*

21. Describe materials or principal components of each product:

a:

b:

c:

22. Do you design and manufacture the complete product?: Yes No If no, what components are purchased by you?:*

YesNo

(Please describe)

23. Is the product under your label?:*

YesNo

(Please describe)

24. Do you maintain and/or service the products?:*

YesNo

(Please provide details)

25. Do you maintain quality control procedures?:*

YesNo

(If yes, describe details of these procedures)

26. Do you maintain complete inventory records of shipments and/or delivery to consignees?:*

YesNo

(If yes, are serial and/or batch numbers shown on the finished product and on shipment invoices?)

YesNo

27. Can the date of manufacture of each product be identified by the factory numbers stamped on it?:*

YesNo

28. Do you keep samples of products involved in your quality control procedures?:*

YesNo

(If yes, how long?)

29. Do you have a formal "Products Recall Plan"?:*

YesNo

30. Do you have a written procedure for the handling of complaints about your products and accidents/injuries involving your products?:*

YesNo

(If yes, please provide details)

31. Is a written record of all such complaints, accidents, injuries maintained?:*

YesNo

Who is the individual or the department responsible to maintain these records?:

32. Is any component in your product(s) considered as a "hazardous substance" under any government regulations?:*

YesNo

If yes, provide descriptions and names of these substances.

33. If you are a distributor and do not actually manufacture the products you sell, then does your manufacturer(s) provide you with vendors liability coverage?:*

YesNo

34. Please let us know if you would be interested in receiving quotes for any of the following coverage:*

PRIOR INSURANCE

35. Who was your insurer in the last 3 years?: (if self-insured, so state)*

36. State limit of liability, SIR or deductible (specify which), retroactive date (if any), rate and premium:

Year Carrier limit DEC/SIR:*

Rate/Premium*

37. If you have been self-insured or had an SIR, who adjusted the claims and established reserves?:*

38. Has any carrier cancelled, restricted or refused to renew your products liability insurance in the past five years?:*

YesNo

(If yes, please explain)

39. Are any of your products intended for use on or in connection with:

Aircraft or missiles?*

YesNo

Watercraft?*

YesNo

Offshore operations?*

YesNo

40. Do you require certificates of insurance from your suppliers?:*

YesNo

(If yes, indicate minimum limit acceptable)

41. Do you provide insurance to your distributor?:*

YesNo

(If so, explain)

42. Are your products designed, tested, labeled and manufactured to meet or exceed all industry of government standards?:*

YesNo

(If no, please explain)

PRODUCTS LIABILITY CLAIM HISTORY

43. Please provide at least five years data on claims-both total losses from first dollar, including expenses and specific date on individual losses paid or reserved for $10,000 or more (first dollar including expenses)

A hard copy of these loses from prior carriers may be required.

(loss amounts must be from first dollar and include expenses)

	Policy Period	Carrier	Number of Claims	Amounts Paid	Reserved	Date Losses Valued
1
2
3
4
5
6

44. How did you hear about us?

PLEASE CHECK TO ENSURE THAT ALL QUESTIONS HAVE BEEN ANSWERED

Copies of the following may be required:

Product brochures/catalogs
Last annual financial statement for applicants with revenues of $5,000,000 and higher

Also attach explanation to questions which may be useful.

Submitting this agreement indicates your acceptance of its terms.

Applicant’s Digital Signature: (Please type name)*

NOTICE TO APPLICANTS: The coverage applied for is solely as stated in the policy. If policy is issued on a "CLAIMS MADE" or "CLAIMS MADE AND REPORTED" basis, it provides coverage only for those claims that are first made against the insured during the policy period unless the extended reporting period option is exercised in accordance with the terms of the policy. If issued on an "OCCURRENCE" basis, the policy provides coverage only for those occurrences that take place during the policy period.

The Insurer will rely upon this application and all such attachments in issuing the policy. If the information in this application or any attachment materially changes between the date this application is signed and the effective date of the policy, the Applicant will promptly notify the Insurer, who may modify or withdraw any outstanding quotation or agreement to bind coverage.

In New York: Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information, or conceals for the purpose of misleading, information concerning any fact material thereto, commits a fraudulent insurance act, which is a crime and shall also be subject to a civil penalty not to exceed five thousand dollars and the stated value of the claim for each such violation.

In all other states; it is a crime for any person to knowingly provide or facilitate in providing any false, incomplete, or misleading information to an insurance company. Penalties may include fines, imprisonment and denial of insurance benefits.

WARRANTY: I warrant to the Insurer, that I understand and accept the notice state above and 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 Insurer evidence its acceptance of this application by issuance of a policy. I authorize the release of claim information from any prior insurer to York-Jersey Underwriters, Inc., 185 Newman Springs Road, Tinton Falls, NJ 07724.