13727 Noel Road, Galleria North Tower II, Suite. 1000, Dallas, Texas 75240
Tel: 800-524-3284 or 972-528-6950 casualtysubmissions@hallmarkgrp.com
General Information:
Name Insured:
Manufacturers Supplemental Application
Commercial General Liability
DBA:
Mailing Address:
State: Zip Code:
Years In Business:
Yes No
New Policy?
Yes No
Renewal?
Website Address: www.
Policy#: Effective Date:
Current Carrier Information:
Carrier:
Limit of Insurance: Deductible: Premium:
Expiration Date:
Attach Copies of the Following:
1. Current Financial Statement:
2. Applicant's Product Brochures:
3. Specimens of Contracts/Guarantees Provided Customers and Contracts with Suppliers of Manufactured Products:
Has Any Similar Coverage Been Canceled or Non-renewed in the Past Five Years?
NoYes
Describe Business Operations:
Name:
Address:
State: Zip Code:
Name and address of parent company and all subsidiaries to be insured: (NOTE: Coverage applies ONLY to those entities
specifically named in a policy we may issue to you.) Identify entities as parent or subsidiaries.
Years In Business:
Attach a Separate Sheet to List Additional Entities to be Insured.
Attached
Hallmark E&S - Manufacturers Supplemental Application Page 1
If Any Division, Product, or Product Group is to be Specifically Excluded From Coverage, Please Indicate:
Hallmark E&S - Manufacturers Supplemental Application Page 2
Have You Merged With or Acquired Any Companies in the Last Three Years?
NoYes
If Yes, Provide Details and Advise How Past Liabilities Were Handled in the Acquisition:
Do You Have a Formal Quality Control Program?
NoYes
If Yes, Provide Details. If No, How Do You Assure the Quality of Your Products?
What Products are Manufactured, Sold, or Distributed?
$
Total Sales
Last Year (000):
Product Type & Brand Name:
Percentage of Sales
Outside US:
%
$
Estimated Sales
Next Year (000):
$
%
$
$
%
$
$
%
$
$
%
$
In What Geographic Areas/States are These Products Sold?
US States/Geographic Areas: Percentage of Sales:
%
Foreign Countries: Percentage of Sales:
%
% %
% %
% %
% %
Estimated Sales Next 12 Months 1st Prior Year
Total Revenue: $ $
Domestic Revenue: $ $
International Revenue: $ $
2nd Prior Year
$
$
$
3rd Prior Year
$
$
$
4th Prior Year
$
$
$
5th Prior Year
$
$
$
Hallmark E&S - Manufacturers Supplemental Application Page 3
Customer #1:
Top Five Customers:
Customer #2:
Customer #3:
Customer #4:
Customer #5:
How Can Your Products Be Identified From Those of Your Competitors?
Do You Agree to Hold All Distributors, Dealers and Suppliers Harmless Against Claims or Suits for Bodily Injury
and Property Damage in Connection With Your Products?
NoYes
Are Any Products Sold or Components used by You Manufactured by Foreign Manufacturers?
NoYes
If Yes, Provide Details With Percent of Cost of Goods Sold:
Are Batch/Product Records, Serial Numbers or Copies of Guarantee/Warranties Maintained to Trace Products?
NoYes
If Yes, Provide Details Including How Long Records Are Maintained:
Are the Products Identified to Ensure Traceability to Date and Place of Manufacturing?
NoYes
Are the Critical Components Identified and Traceable to the Original Source?
NoYes
Are the Raw Materials Traceable Back to the Original Source?
NoYes
Does Any Manufacturer Provide You Protection for Any Products That You Distribute?
NoYes
If Yes, Which Products and Provide Details:
If Any Products become Component Parts of Another Company's Products, Supply Details and Include End Use Applications. If Sold to
be Repackaged Under Another name, Supply the Eventual Name and Potential Customers:
Are Any New Products to be Introduced/Manufactured During Next Year?
NoYes
Do You Manufacture Products For Any Of The Following Industries?
PharmaceuticalAviation Motor Vehicles
Chemical Medical Health Care Biotechnology Children's Furniture Children's Toys Sporting Goods
Food Manufacture/Processing Meat Processing/Slaughter Houses Seafood Processing Offshore
Industrial/Pressurized Piping
If Yes, Describe:
If Yes, Describe Product and Expected Sales:
Hallmark E&S - Manufacturers Supplemental Application Page 4
Are There Any Present Situations Which Might Give Rise to an Incident Causing a Product Recall?
NoYes
If Yes, Which Products and Provide Details:
Have You Been Cited by Any Regulatory Agency For Violations from Business Activity Involving Your Product?
NoYes
If Yes, Which Products and Provide Details:
Does Any Manufacturer Provide You Protection for Any Products That You Distribute?
NoYes
If Yes, Which Products and Provide Details:
What Percentage of Your Manufacturing Sales are based on:
%
Customer Specifications:
%
Your Design:
Are You ISO 9000 Certified?
NoYes
If Yes, Year Recognized:
Do You Service or Repair Your Products or Others' Products at Your Premise or at Another Location?
NoYes
If Yes, Which Products and Provide Details:
Do You have Any Discontinued Products?
NoYes
If Yes, Provide Reasons for Discontinuing:
During the Past Five Years, Has Any Insurer Ever Canceled or Non-renewed Similar Insurance for You?
NoYes
If Yes, Please Explain:
During the Past Five Years, Has Your Insurance Been Canceled For Non-Payment of Premium By Any Carrier?
NoYes
If Yes, Please Explain:
Has Any Product Ever Been Recalled?
NoYes
If Yes, Provide the Following Details:
By What Agency?Date of Recall:
OrderedVoluntary
Product Involved:
Reason For Recall and How Discovered:
What Was the Remedy for the Problem?
Were the Federal/State Authorities Notified?
NoYes
If Yes, On What Date?
Do You Have a Formalized Recall Program?
NoYes
If Yes, Please Attach a Copy.
Attached
If No, Do You Have an Informal Plan?
NoYes
If Yes, Please Attach a Copy.
Attached
Hallmark E&S - Manufacturers Supplemental Application Page 5
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.
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.
Is Your Company Aware of Any Occurrences, Facts, Circumstances, Incidents, Situations, 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?
NoYes
IMPORTANT- The 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. 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's Signature:
Date:
Please email the completed application to: submissionsGL@hallmarkes.com
Applicant: Title:
FEIN#:
Agent/Broker Name:
Hallmark E&S - Manufacturers Supplemental Application Page 6
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.
FRAUD WARNING (Continued)
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