HS SA MP 11 17
MANUFACTURING & PRODUCTS LIABILITY SUPPLEMENTAL APPLICATION
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. _________________________________________ _________________________________________