PRODUCTS LIABILITY INSURANCE QUESTIONNAIRE

PRODUCTS LIABILITY INSURANCE QUESTIONNAIRE
Full Name
Principal Address
EMail
example@example.com
Subsidiaries or Divisions
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

Rows	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:

Rows	Policy Period	No. of Claims	Total Amount Incurred
1
2

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

Rows	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?
If yes please give details

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

Rows	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?
(c) Do you export products or have foreign operations?
(d) Could any or your products or services be used on or in connection with:
aircraft/missile/aerospace
watercraft or offshore?
transportation/ transit?
life support service?
Do you make or handle any product that is explosive, flammable, or poisonous either by itself or in combination with other materials?
Could any or your products be classified as:
Pharmaceuticals or medical devices
Cosmetics
Are any of your products sold under another's name or label?
Do you purchase materials or components from others?
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?
If assembled by others, do you supervise?
If installed by others, do you supervise or furnish instruction for the installation?
If you maintain and service your products, attach a copy of your standard service contract.
Who packages your products?
Who designs your packaging?
Who supply the packaging materials?
How are they packed when sold?
Is any sterile packaging invloved?
Do you package for others?
Do you package under trade names other than your own?
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?
Do they hold you harmless or insure you?
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
Do you have a written product recall plan? If yes, please attach
Have you ever recalled products because of a potential product safety hazard? If yes, please attach details and indicate percent of recovery.
Has any management issued a written policy statement on product safety which has been communicated to all employees? If yes, please attach.
Do you have a written product safety program for which specific individuals have responsibility for implementation? If yes, attach copy or outline.
PRODUCT DESIGN
Do you carry out your own design work?
Do you maintain records of design changes and reasons justifying these changes?
Are your designs subject to independent external review, testing or certification? If so, attach details and dates
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?
QUALITY CONTROL AND TESTING
Are written testing procedures followed?
Do you have a quality control manager responsible only to top management?
Supplies and components:
Are they ordered to your specifications?
Have you determined which ones are critical to the safety of your final product?
List those critical items, indicating whether testing is on a sample basis or on all units
Are warranties obtained from all suppliers?
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?
How far back are your records kept? (specify date)
If your products are manufactured to the specification of your customers, do they test the product upon receipt?
Do you receive an acceptance sign-off from your customer?
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?
written instructions?
other means? (attach details)
Are warnings / instructions in English?
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?
top management?
others? (attach details)
Do you expressly disclaim or limit warranties for your products?
Are all warranties and/or disclaimers reviewed by legal counsel?
Do you provide any specific training or instructions for the ultimate user in the Proper use of your product? If yes, please describe.
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?
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?
to whom it was sold, and the date of sale?
who supplied the parts and which of these go into the final products?
Do you maintain copies of old instructions or operation manuals and advertising materials?
Do you have a written procedure for obtaining information about product complaints, accidents and injuries involving your product?
Have you made distributors aware of your desire for prompt notice of all complaints, accidents and injuries involving your product?
Does your 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 product involved go to the person responsible for product safety?
Are results used for improving the product/process procedures?
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.
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
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: