Product Liability Insurance Application

Product Liability Insurance Application
SECTION 1: COMPANY DETAILS
1. Company Name:
Street Address:
City:
State:
Zip:
Telephone:
Email:
example@example.com
Website:
Legal Status:

Individual Partnership Corporation Joint Venture Other:
Contact Name:
Phone:
Federal Tax ID Number:
Number of years in business:
2. Is the Applicant controlled by, owned by, or commonly owned, affiliated, or associated with any other organization?

Yes No
If yes, provide details:
3.Total experience in this type of business:
4.Number of Full-time Employees:
Part-time:
SECTION 2: SPECIFIED PRODUCTS AND COMPLETED OPERATIONS
1.Provide the following information for those products and/or services for which the Applicant wants coverage. Only those products and services listed below will be considered for coverage.

M: manufacturer W: wholesaler R: retailer I: importer MR: manufacturer’s rep. C: consumer direct O: other (describe)
Does Applicant

Products sold to:

Products and Services (or specific categories)

No. of Years

% of Gross Receipts

Install

Repair or Service

Sold To [W]

Sold To [R]

Sold To [C]

Sold To [O]

Total gross receipts from all products and services listed above:
Estimated annual gross receipts for the coming year:
Annual gross receipts: (i) last twelve months:
1st (ii)1 prior year:
3. Is the Applicant presently considering any change in the mix of products, including adding new products or services, for the coming year? If yes, provide details

Yes No
If yes, provide details:
4. Has the Applicant discontinued or is it considering discontinuing any product or service listed above? If yes, provide details

Yes No
If yes, provide details:
5. Are any of the Applicant’s products or services used in connection with aircraft/missiles/aerospace?

Yes No
If yes, provide details:
SECTION 3: PROCESSING AND QUALITY CONTROL
1. Do any products, ingredients, or components thereof originate outside the United States? If yes, please specify:

Yes No
a.The country(ies) of origin:
b. The name of each organization manufacturer, distributor, or supplier:
2. Do others manufacture, assemble, package or install products under the Applicant’s name or label?

Yes No
If yes, provide the name(s) and address(es) of contract manufacturer(s):
3. Does the Applicant manufacture, assemble, package, or install products for others under their name or label?

Yes No
If Yes, Explain
4. Does the Applicant have a quality control and testing procedure?

Yes No
If yes, how long does the Applicant keep quality control and testing records?
5. Can the Applicant identify its product(s) from those of competitors?

Yes No
6. Do all records show to whom and the date each product was sold?

Yes No
7. Does the Applicant require certificates of insurance evidencing Products Liability Insurance from suppliers?

Yes No
8.Who designs the Applicant’s products?
9. Are product designs reviewed, tested, and verified by others?

Yes No
10. Does the Applicant have a specific program to withdraw known or suspected defective products from the market?

Yes No
11. Has the Applicant ever recalled or is it considering recalling any product(s)?

Yes No
12. Have the Applicant’s products, ingredients, or components thereof ever been the subject of any investigation,enforcement action, or notice of violation of any kind by any governmental, quasi-governmental, administrative,regulatory, or oversight body?

Yes No
If yes, provide details:
SECTION 4: MANUFACTURING AND DISTRIBUTION
1.Are all the products sold considered “Generally Regarded Safe” by the FDA?

Yes No
2.Do you import any products from other countries?

Yes No
If yes, please list countries:
3.Do you export products or have foreign operations?

Yes No
If yes, please provide details:
4. Do you make or sell any of the following products? (Select any/all that apply)

Vitamins/Supplements Aerosol Products Electric Curlers/Straighteners Acetone Products Invasive Body Inks
5. Do you make or handle any products that are explosive, flammable, or poisonous either by itself or in combination with other materials?

Yes No
6. Could any of your products be classified as pharmaceuticals?

Yes No
If yes, please provide details:
7.Do others private-label your products?

Yes No
If yes, please provide details:
SECTION 5: INSURANCE INFORMATION
1. Limits of Liability requested:
Deductible
2. Do you currently have liability insurance

Yes No
If Yes Current Insurance Company
Expiring Premium
Current Limits of Liability
Current Deductible/SIR:
Retroactive Date/Prior Acts Date (if applicable):

Month Day Year
Date
Has any insurer declined, cancelled, or nonrenewed any product liability insurance or any similar insurance on behalf of any person(s) or organization(s) proposed for this insurance?

Yes No
If yes, please provide details:
SECTION 6: CLAIMS HISTORY
Has any claim for Product Liability been made against any person(s) or organization(s) proposed for this insurance during the last 5 years?

Yes No
For Exisiting Business Please Provide Current Valued 5yr Loss Runs (Loss History Report).

If You're A New Venture A Signed No Loss Letter Will Be Required Prior To Bind
Upload Loss History Report

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Cancel of
Is (are) any person(s) or organization(s) proposed for this insurance aware of any fact, incident, circumstance,situation, condition, defect, or suspected defect which may result in a Products Liability claim?

Yes No
If yes, please provide details:
SECTION 7: ADDITIONAL INFORMATION
1.Please attach the following: Brochures, Labels, and Instructions.
Upload Supporting Documents

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Additional Documents May Be Required At The Time Of Bind Cancel of
SECTION 7: WARRANTIES
NOTICE TO THE APPLICANT - PLEASE READ CAREFULLY
No fact, circumstance or situation indicating the probability of a claim or action for which coverage may be afforded by the proposed insurance is now known by any person(s) or organization(s) proposed for this insurance other than that which is disclosed in this application. It is agreed by all concerned that if there is knowledge of any such fact, circumstance or situation, any claim, subsequently emanating therefrom shall be excluded from coverage under the proposed insurance.

For the purpose of this application, the undersigned authorized agent of the person(s) and organization(s) proposed for this insurance declares that to the best of his/her knowledge and belief, after reasonable inquiry, the statements in this application and in any attachments, are true and complete. The Company is authorized to make any inquiry in connection with this application. Signing this application does not bind the Company to provide or the Applicant to purchase the insurance. If the information in this application and any attachment materially changes between the date this application is signed and the effective date of the policy, the Applicant will promptly notify CityScape Insurance, LLC, who may modify or withdraw any outstanding quotation or agreement to bind coverage.
Products Liability Insurance Application

The undersigned declares that the person(s) and organization(s) proposed for this insurance understand that:

(i) the policy for which this application is made applies only to “Claims” first made during the “Policy Period”; and

(ii) completely exhausted by “Claim Expenses” and, in such event, the Company will not be liable for “Claim Expenses” or the amount of any judgment or settlement to the extent that such costs exceed the limits of liability in the policy.

WARRANTY: I/We warrant to the Company, that I/We understand and accept the notice stated above and that the information contained herein is true and that it shall be the basis of the policy and deemed incorporated therein, should the Company evidence its acceptance of this application by issuance of a policy.

Note: This application is signed by undersigned authorized agent of the Applicant(s) on behalf of the Applicant(s) and its partners, directors, officers, and employees. owners,

unless amended by endorsement, the limits of liability contained in the policy shall be reduced, and may be
Print Name
Date:

Month Day Year
Date
Please verify that you are human *
AZ Lic # 1800011010 | CO: 598458 | FL Lic # W519333 | NM Lic # 1800012011 | TX Lic # 1995214
Should be Empty:

Product Liability Insurance Application

SECTION 1: COMPANY DETAILS

SECTION 2: SPECIFIED PRODUCTS AND COMPLETED OPERATIONS

Does Applicant

SECTION 3: PROCESSING AND QUALITY CONTROL

SECTION 4: MANUFACTURING AND DISTRIBUTION

SECTION 5: INSURANCE INFORMATION

SECTION 6: CLAIMS HISTORY

SECTION 7: ADDITIONAL INFORMATION

SECTION 7: WARRANTIES

NOTICE TO THE APPLICANT - PLEASE READ CAREFULLY