Fillable EV Fertilizer Manufacturing Supplemental Application (Kinsale Insurance)

Fill Online, Printable, Fillable, Blank EV Fertilizer Manufacturing Supplemental Application (Kinsale Insurance) Form

Use Fill to complete blank online KINSALE INSURANCE pdf forms for free. Once completed you can sign your fillable form or send for signing. All forms are printable and downloadable.

EV Fertilizer Manufacturing Supplemental Application (Kinsale Insurance)

On average this form takes 42 minutes to complete

The EV Fertilizer Manufacturing Supplemental Application (Kinsale Insurance) form is 6 pages long and contains:

  • 1 signature
  • 11 check-boxes
  • 159 other fields

Country of origin: US
File type: PDF

Use our library of forms to quickly fill and sign your Kinsale Insurance forms online.

BROWSE KINSALE INSURANCE FORMS

Related forms
Fill has a huge library of thousands of forms all set up to be filled in easily and signed.
Fill in your chosen form
Sign the form using our drawing tool
Send to someone else to fill in and sign.
find another form
 
Page 1 of 6
FERTILIZER SUPPLEMENTAL APPLICATION
COMPLETE IN ADDITION TO ACORD APPLICATIONS.
ATTACH ADDITIONAL SHEETS AS NECESSARY.
ANSWER ALL QUESTIONS. If not applicable, indicate N/A.
1)
Named Insured:
Brokerage/Broker:
Agency/Agent:
Renewal?
Yes No
Policy Number:
Effective Date:
Website:
2) Current Carrier Information:
Carrier:
Limit of Insurance:
Deductible:
Premium:
Offering renewal?
Yes No
Claims made?
Yes No Retroactive date:
Please attach copies of the following:
a) Currently valued five year loss runs, including claim detail for all losses open or exceeding $15,000
b) MSDS sheets for all products
c) Applicant’s product brochures or catalog if a website is not available
3) Mailing Address:
City: State: Zip Code:
4) Your premise address (if different from above):
City: State: Zip Code:
5) If any subsidiary, product or product group is to be specifically excluded from coverage, please indicate:
Are these products covered elsewhere? Yes No
6) If you have operated under a different business name in the last ten years, please list:
GENERAL INFORMATION
Kinsale Insurance Company
P. O. Box 17008
Richmond, VA 23226
(804) 289-1300
www.kinsaleins.com
Page 2 of 6
7) What are your operations?
8) Please complete the following for your top 5 products/product categories:
Type of Product or Product Category
Total Sales
Last Term
Projected
Sales
Upcoming
Term
Typical End Use/End Users
9) Please provide a breakdown of your product sales:
Industrial
Farm Use
Nursery or
Greenhouse Use
Direct to
Consumer Retail
Wholesale
to Consumer
Retailers
Other
Wholesale
Distribution
Other
(please clarify
below)
Sold in the United
States or Canada
%
%
%
%
%
%
Sold
Internationally
%
%
%
%
%
%
TOTAL
=
100%
10) Do your products contain manure, frass, animal byproduct or other biological materials? Yes No
If yes, please describe hazardous pathogen screening or sterilization procedures:
11) Do you sell any fertilizers blended with pesticides, fungicides, herbicides, et cetera? Yes No
If yes, please list products and provide details:
12) Do you sell any fertilizers blended with seeds (such as lawn patch or turf spot repair products)? Yes No
13) Do you perform any contract manufacturing, repackaging, blending, or private labeling for Yes No
others? If yes please provide a list of the products, for whom you are performing these services, and percentage of
sales:
14) Are your products used as an ingredient or component of another company’s products? Yes No
If yes, please provide a list of the products, the company(ies) utilizing, and the end product your products are used in:
15) Do you perform any product formulation/development, consulting or laboratory testing Yes No
services for others? If yes, please clarify:
OPERATIONS
Page 3 of 6
16) Do you or any subcontractors working on your behalf provide any application, spreading Yes No
or other installation services for others? If yes, please clarify:
17) Are you launching any new products this year? If yes, please describe: Yes No
18) Do you import any products or components? Yes No
a. If yes, what percentage of products are directly imported? __________ %
b. Do you take possession of the products? Yes No
19) Do you have a formal quality control program? Yes No
If yes, provide details. If no, how do you assure the quality of your products?
20) Do you have any discontinued products? Yes No
If yes, please explain the reasons for discontinuing.
21) Do you maintain tracing records of component and raw material sources? Yes No
If yes, confirm how long these records are maintained:
22) Are batch or product records, serial numbers or copies of guarantee/warranty cards Yes No
maintained that would facilitate tracing whereabouts of products? If yes, confirm how
long these records are maintained:
23) In the event that it becomes necessary to recall a product, do you have a recall plan in place? Yes No
a. Do you have Product Recall insurance? Yes No
b. What means would be used to secure the return and disposal of the product?
24) Have you ever had a product recall event? Yes No
a. If yes, supply the following details: Date of recall(s):
b. Voluntary? Ordered? By what agency?
c. Product(s) involved:
d. Reason for recall and how discovered:
e. What was the remedy of the problem?
f. What percentage of recalled goods were returned/repaired?
25) Are there any present situations that might give rise to an incident causing a product recall? Yes No
If yes, supply details.
26) Have you been cited by any regulatory agency for violations arising out of business Yes No
activity involving your product, including any inquiries or investigations concerning the
efficacy, adequacy of labeling, hazardous contents or safety of your product(s)?
If yes, please attach details and copies of all regulatory letters, bulletins, reports,
inspections, and other pertinent documentation.
Page 4 of 6
27) Is your premise located in area that is:
Urban Rural Industrial Suburban Other (please clarify below)
28) Please clarify neighboring occupancies within 100 feet of your premise:
North
South
East
West
Occupancy
Distance
29) How many miles is your premise from the closest city, community, town, residential neighborhood or apartment
complex?
30) Are explosives or flammables stored or processed on site, including but not limited to Yes No
anhydrous ammonia or ammonium nitrate?
a. If yes, please list product(s) and quantity:
b. Are explosive/flammable materials stored in NFPA/IFC compliant containment? Yes No
31) Have you had any Product Liability claims that were or were not covered by insurance? Yes No
If yes, please provide details.
32) During the past five years, has any insurer ever canceled or non-renewed similar Yes No
insurance to any applicant or has your insurance been canceled for nonpayment of
premium by any insurance or finance company. If yes, please explain.
33) Is your company aware of any occurrences, facts, circumstances, incidents, situations, Yes No
damages or accidents (including but not limited to allegations of faulty or defective products,
product failure, product dispute bodily injury or property damage) arising out of or related to
your products that a reasonably prudent person might expect to give rise to a claim or lawsuit
whether valid or not which might directly or indirectly involve the company?
FRAUD WARNING
NOTICE TO ALABAMA, ALASKA, ARIZONA, ARKANSAS, CALIFORNIA, CONNECTICUT, DELAWARE, GEORGIA, IDAHO, ILLINOIS, INDIANA, IOWA, KANSAS,
MARYLAND, MASSACHUSETTS, MICHIGAN, MINNESOTA, MISSISSIPPI, MISSOURI, MONTANA, NEBRASKA, NEVADA, NEW HAMPSHIRE, NORTH CAROLINA,
NORTH DAKOTA, OREGON, RHODE ISLAND, SOUTH CAROLINA, SOUTH DAKOTA, TEXAS, UTAH, VERMONT, WASHINGTON, WEST VIRGINIA, WISCONSIN,
AND WYOMING APPLICANTS: In some states, 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, for the purpose of misleading, conceals information
concerning any fact material thereto, may commit a fraudulent insurance act which is a crime in many states.
PREMISES INFORMATION
OTHER
Page 5 of 6
NOTICE TO COLORADO APPLICANTS: It is unlawful to knowingly provide false, incomplete or misleading facts or information to an insurance company for
the purpose of defrauding or attempting to defraud the company. Penalties may include imprisonment, fines, denial of insurance and civil damages. Any
insurance company or agent of an insurance company who knowingly provides false, incomplete or misleading facts or information to a policy holder or
claimant for the purpose of defrauding or attempting to defraud the policyholder or claiming with regard to a settlement or award payable for insurance
proceeds shall be reported to the Colorado Division of Insurance within the Department of Regulatory Agencies.
NOTICE TO DISTRICT OF COLUMBIA APPLICANTS: WARNING: It is a crime to provide false or misleading information to an insurer for the purpose of
defrauding the insurer or any other person. Penalties include imprisonment and/or fines. In addition, an insurer may deny insurance benefits if false
information materially related to a claim was provided by the applicant.
NOTICE TO FLORIDA APPLICANTS: Any person who knowingly and with intent to injure, defraud or deceive any insurance company files a statement of
claim containing any false, incomplete or misleading information is guilty of a felony of the third degree.
NOTICE TO HAWAII APPLICANTS: For your protection, Hawaii law requires you to be informed that presenting a fraudulent claim for payment of a loss or
benefit is a crime punishable by fines or imprisonment, or both.
NOTICE TO KENTUCKY APPLICANTS: Any person who knowingly and with intent to defraud any insurance company or other person files an application for
insurance 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.
NOTICE TO LOUISIANA APPLICANTS: Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents
false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison.
NOTICE TO MAINE APPLICANTS: It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the purpose of
defrauding the company. Penalties may include imprisonment, fines, or denial of insurance benefits.
NOTICE TO NEW JERSEY APPLICANTS: Any person who includes any false or misleading information on an application for an insurance policy is subject to
criminal and civil penalties.
NOTICE TO NEW MEXICO APPLICANTS: Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents
false information in an application for insurance is guilty of a crime and may be subject to civil fines and criminal penalties.
NOTICE TO NEW YORK APPLICANTS: Any person who knowingly and with intent to defraud an 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 $5,000 and the stated value
of the claim for each such violation.
NOTICE TO OHIO APPLICANTS: Any person who, with intent to defraud or knowing that he/she is facilitating a fraud against an insurer, submits an application
or files a claim containing a false or deceptive statement is guilty of insurance fraud.
NOTICE TO OKLAHOMA APPLICANTS: WARNING: Any person who knowingly, and with intent to injure, defraud or deceive any insurer, makes a any claim
for the proceeds of an insurance policy containing any false, incomplete or misleading information is guilty of a felony.
NOTICE TO PENNSYLVANIA APPLICANTS: Any person who knowingly and with intent to defraud any insurance company, or other person, files an application
for insurance or statement of a 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 subjects the person to criminal and civil penalties.
NOTICE TO TENNESSEE APPLICANTS: It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the purpose
of defrauding the company. Penalties include imprisonment, fines and denial of insurance benefits.
NOTICE TO VIRGINIA APPLICANTS: It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the purpose
of defrauding the company. Penalties include imprisonment, fines and denial of insurance benefits.
The Applicant acknowledges that the answers provided herein are based on a reasonable inquiry and/or investigation. The Applicant warrants that the
above statements and particulars together with any attached or appended documents are true and complete and do not misrepresent, misstate or omit
any material facts.
The Applicant agrees to notify us of any material changes in the answers to the questions on this questionnaire which may arise prior to the effective
date of any policy issued pursuant to this questionnaire and the Applicant understands that any outstanding quotations may be modified or withdrawn
based upon such changes at our sole discretion.
Completion of this form does not bind coverage. Applicant’s acceptance of the company’s quotation is required prior to binding coverage and policy
issuance.
Page 6 of 6
All written statements and materials furnished to the company in conjunction with this application are hereby incorporated by reference into this
application and made a part of this application.
Applicant: Title:
FEIN #:
Applicant’s Signature: Date:
Agent/Broker Name:
click to sign
signature
click to edit
Download
Save PDF to desktop
Email
Email completed PDF
Send for Signing
Email for others to sign
Print
Print document
Choose a Field
Click on a field and
select the person that should complete it
Want to add a signature?
You can add a signature field
and assign it to someone else
to sign
Choose a Field
Click on a field and
select the person that should complete it

EV Fertilizer Manufacturing Supplemental Application (Kinsale Insurance)

This document is locked as it has been sent for signing.

You have successfully completed this document.

Other parties need to complete fields in the document. You will recieve an email notification when the document has been completed by all parties.

This document has been signed by all parties.

Completed 16 July 2020

Message

View Audit Log
Print With Audit Log
Duplicate Document