PRODUCTS LIABILITY INSURANCE QUESTIONNAIRE

PRODUCTS LIABILITY INSURANCE QUESTIONNAIRE
Full Name
Principal Address
EMail
example@example.com
Subsidiaries or Divisions
Sole ventureJoint ventureother
ManufactureWholesalerRetailerImporterExporter
f Years in business under present name
g Prior experience in this business under another name
h Present affiliation with other firms
i Sales and Receipts estimated for new policy year
J Turnover for last 12 months

	Product and Services	Years Involved	Principal End User	% of Gross Annual Sales
1
2
3

NOTE: (Attach brochures, catalogs, labels instruction manuals, annual reports and Product Surveys)

CLAIMS HISTORY- 5 years or more Total aggregate losses, from ground up, including defense costs:

	Policy Period	No. of Claims	Total Amount Incurred
1
2

Individual losses, valued $5,000 or more from the ground up, including defence costs:

	Date of Occurrence	Product Involved	Year Mfgd	Describe Occurrence & Injury or Damage	Amount Paid & Reserved
1
2
3

(c) Are you aware of any other incidents which may result in claims against you?

YesNo
If yes please give details

PRODUCT AND SALES DATA (a) For Principal Products or Service, indicate:

	Total Sales or Receipts	Product or Service	% of Total Sales	No. of units Sold
Past 12 months
2nd Prior Year
3rd Prior Year
4th Prior Year
5th Prior Year

What percentage of total sales are replacement parts? (%)
(b) Do you import products or component parts?

YesNo
(c) Do you export products or have foreign operations?

YesNo
(d) Could any or your products or services be used on or in connection with:
aircraft/missile/aerospace

YesNo
watercraft or offshore?

YesNo
transportation/ transit?

YesNo
life support service?

YesNo
Do you make or handle any product that is explosive, flammable, or poisonous either by itself or in combination with other materials?

YesNo
Could any or your products be classified as:
Pharmaceuticals or medical devices

YesNo
Cosmetics

YesNo
Are any of your products sold under another's name or label?

YesNo
Do you purchase materials or components from others?

YesNo
PLEASE EXPLAIN ALL OF THE ABOVE 'YES' ANSWERS BELOW:
i Briefly describe how your products are to be used:
PROCESSING
Do others assemble your products?

YesNo
If assembled by others, do you supervise?

YesNo
If installed by others, do you supervise or furnish instruction for the installation?

YesNo
If you maintain and service your products, attach a copy of your standard service contract.

YesNo
Who packages your products?
Who designs your packaging?
Who supply the packaging materials?
How are they packed when sold?
Is any sterile packaging invloved?

YesNo
Do you package for others?

YesNo
Do you package under trade names other than your own?

YesNo
MARKETING
(a) Percentage of total sales to: (b) Suppliers and Distributors of your products (i) Do you hold them harmless or insure them? (ii) Do they hold you harmless or insure you?
Wholesalers %
Retailers %
Consumers%
Suppliers and distributors of your products
Do you hold them harmless or insure them?

YesNo
Do they hold you harmless or insure you?

YesNo
If yes to either i or ii, please explain
LOSS PREVENTION
Have your products ever been subject to inquiry or investigation in relation to product safety by any governmental agency? If yes, please attach

YesNo
Do you have a written product recall plan? If yes, please attach

YesNo
Have you ever recalled products because of a potential product safety hazard? If yes, please attach details and indicate percent of recovery.

YesNo
Has any management issued a written policy statement on product safety which has been communicated to all employees? If yes, please attach.

YesNo
Do you have a written product safety program for which specific individuals have responsibility for implementation? If yes, attach copy or outline.

YesNo
PRODUCT DESIGN
Do you carry out your own design work?

YesNo
Do you maintain records of design changes and reasons justifying these changes?

YesNo
Are your designs subject to independent external review, testing or certification? If so, attach details and dates

YesNo
Are your products designed, tested, labeled and manufactured:
to meet or exceed all government and industry standards?

YesNo
for optimum safety in spite of misuse or abuse?

YesNo
QUALITY CONTROL AND TESTING
Are written testing procedures followed?

YesNo
Do you have a quality control manager responsible only to top management?

YesNo
Supplies and components:
Are they ordered to your specifications?

YesNo
Have you determined which ones are critical to the safety of your final product?

YesNo
List those critical items, indicating whether testing is on a sample basis or on all units

YesNo
Are warranties obtained from all suppliers?

YesNo
Final Products:
i Briefly describe tests applied before sales:
What percentages are tested?
Are records of quality control test results kept so that you can identify at a later date what tests have been applied to a given product at a given time?

YesNo
How far back are your records kept? (specify date)

YesNo
If your products are manufactured to the specification of your customers, do they test the product upon receipt?

YesNo
Do you receive an acceptance sign-off from your customer?

YesNo
INSTRUCTIONS/WARNINGS/ADVERTISING/WARRANTIES

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?

YesNo
written instructions?

YesNo
other means? (attach details)

YesNo
Are warnings / instructions in English?

YesNo
Are instructions, warnings, labels and advertising texts subject to review, to ensure that they are complete and easily understood by the ultimate user, so as to avoid overstatement in relation to safety, or omissions in relation to hazards, by
legal counsel?

YesNo
top management?

YesNo
others? (attach details)

YesNo
Do you expressly disclaim or limit warranties for your products?

YesNo
Are all warranties and/or disclaimers reviewed by legal counsel?

YesNo
Do you provide any specific training or instructions for the ultimate user in the Proper use of your product? If yes, please describe.

YesNo
Are salesmen and distributors made aware of your desire to be informed of Cases where your product is used for a purpose for which was not designed?

YesNo
LOSS CONTROL AND DEFENSE
a Explain how you can identify your products and parts from similar competitors products and parts
Can you determine, based on available records for all products you have sold:
when any given product was manufactured?

YesNo
to whom it was sold, and the date of sale?

YesNo
who supplied the parts and which of these go into the final products?

YesNo
Do you maintain copies of old instructions or operation manuals and advertising materials?

YesNo
Do you have a written procedure for obtaining information about product complaints, accidents and injuries involving your product?

YesNo
Have you made distributors aware of your desire for prompt notice of all complaints, accidents and injuries involving your product?

YesNo
Does your procedure provide for examining and preserving any allegedly defective product with the results of such examination recorded?

YesNo
Do reports on complaints, accidents, injuries, and the examination of product involved go to the person responsible for product safety?

YesNo
Are results used for improving the product/process procedures?

YesNo
INSURANCE REQUESTED:
a Limit per incident
a Limit per year
c Proposed effective date

MonthDayYear
Date
Has any insurer ever cancelled, restricted or refused to renew your liability Insurance? If yes, please explain.

YesNo
ADDITIONAL EXPLANATION TO THE QUESTIONS DESIGNATED
I/We declare that the statements and particulars in this proposal are true and that I/We have not mis-stated or suppressed any material facts. I/We agree that this proposal, together with any other information supplied by me/us shall form the basis of any contract of insurance effected thereon. I/We undertake to inform insurers of any material alteration to these facts whether occurring before or after commencement of the contract of insurance.
Signature

Clear
Name
Title
Date

MonthDayYear
Date
Should be Empty:

PRODUCTS LIABILITY INSURANCE QUESTIONNAIRE

(d) Could any or your products or services be used on or in connection with:

Could any or your products be classified as:

PROCESSING

MARKETING

Suppliers and distributors of your products

LOSS PREVENTION

PRODUCT DESIGN

Are your products designed, tested, labeled and manufactured:

QUALITY CONTROL AND TESTING

Supplies and components:

Final Products:

INSTRUCTIONS/WARNINGS/ADVERTISING/WARRANTIES

Are instructions, warnings, labels and advertising texts subject to review, to ensure that they are complete and easily understood by the ultimate user, so as to avoid overstatement in relation to safety, or omissions in relation to hazards, by

LOSS CONTROL AND DEFENSE

Can you determine, based on available records for all products you have sold:

INSURANCE REQUESTED: