HS SA MP 11 17
Date: __________
Named of Insured: ____________________________________________________________________________________________
Describe all business operations conducted by the applicant: __________________________________________________________
1. General Information:
Location of risk: ______________________________________________________________________________________________
How long has the applicant been in business at this location? ______
Insured Website: _____________________________________________________________________________________
Applicant is a: Manufacturer Wholesaler Retailer Importer Manufacturers’ Representative
Sales: Prior Year: ______________ Current Year: ___________________
2. Product Information:
Give detailed description of your product and what the product is designed to do:_________________________________
Of what materials, components, or ingredients products primarily composed? ____________________________________
If food products are ingredients all natural? Yes No
Location(s) from which product(s) are manufactured by the applicant: ___________________________________________
Location(s) from which product(s) are distributed directly by the applicant: _______________________________________
Are all products sold under your label? (If no, describe) ________________________________________________________
Do you manufacture the complete product? (If no, what component parts are purchased) ___________________________
Are any parts purchased from foreign manufacturers? (If yes, explain) ____________________________________________
Do you assemble the product(s)? Yes No
Do you package the product? Yes No
Do you maintain and or service the products? (If yes, explain) __________________________________________________
Is any product installation performed by the applicant/employees? Yes No
If no, does the installer supply any parts not manufactured by the applicant? _______________________________
Is any of the work performed by subcontractors? Yes No
If yes, what type and percentage: __________________________________________________________________
Are certificates required from all subcontractors as proof of General Liability insurance? Yes No
Do subcontractors name you as additional insured on their General Liability policy? Yes No
3. Customers:
List your 5 largest customers and their industries:
Customer: Industries:
1. _________________________________________ _________________________________________
2. _________________________________________ _________________________________________
3. _________________________________________ _________________________________________
4. _________________________________________ _________________________________________
5. _________________________________________ _________________________________________
HS SA MP 11 17
4. Safety:
Has the product been tested & approved by (FDA, UL Labs, EPA, and CPSC)? Yes No
If yes, which product and which agency? ____________________________________________________________
Has your product ever been subject to any inquiry or investigation by any government agency concerning the efficiency,
adequacy of labeling, hazardous contents or safety? Yes No
If yes, attach full details: _________________________________________________________________________
Is product provided with label, brochures, warranties or instructions? Yes No
If yes, describe (attach full details): _________________________________________________________________
Does the applicant have a written recall program in place? Yes No
Does the applicant have a written Quality Control program in place? Yes No
Has any insurer even cancelled or refused to issue or renew your products liability insurance? Yes No
If yes, attach full details: _________________________________________________________________________
5. Customer Support and Field Performance:
What is the most likely product loss scenario? _______________________________________________________________
What are the most common failure modes in your operation? __________________________________________________
What are the most likely consequences of each failure? _______________________________________________________
What are the typical reasons for a return or a request for a refund? _____________________________________________
6. Loss Information:
Please provide a summary of claims, incidents, and losses over the past 5 years (longer if available):
Claims Paid
Reserves Open
Valuation Date
Please provide an explanation for any losses in excess of $10,000: _______________________________________________
7. Additional Insured:
Are you listed as additional insured vendors on any manufacturers policy in which you receive manufactured components
or products? Yes No
List any Additional Insureds and why they are required:
Additional Insured Information
Applicant’s Statement
Applicant hereby attests that the information contained herein is true and accurate to the best of his/her knowledge, information
and belief.
_____________________________________ _____________________________ ________________
Signature of Applicant / Title Print Name Date
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