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PRODUCT LIABILITY SUPPLEMENTAL APPLICATION (Risk Placement Services, Inc.)

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8700 EAST NORTHSIGHT BLVD., SUITE #200 • SCOTTSDALE, ARIZONA • 85260-3669 PHONE 800-243-1782 • FAX 480-951-9722
PRODUCT LIABILITY SUPPLEMENTAL APPLICATION
(Include Acord application)
Applicant’s Name: _____________________________ Location Address: _____________________
Mailing Address: _____________________________ _____________________
_____________________________ _____________________
1. APPLICANT
a. Full name of all entities past and/or present to be Named Insured’s: ____________________________________________
___________________________________________________________________________________________________
b. Principal address: _______________________________________________________________________
c. Number of employees: Total ________ Full-time _______ Part-time _______ Seasonal ______
d. Is any of your work subcontracted to others? Yes No
e. Please check one of the following: Corporation Proprietorship LLC Other ______________
f. Years in business under present name: __________
2. POLICY
Insurance Requested Present Insurance
a. Limits of Liability:
b. Deductible/SIR:
c. Retroactive Date:
d. Present Insurer:
Occurrence: Claims made:
e.
Was tail coverage purchased? Yes No
f. Has insurer ever cancelled, restricted, or refused to renew
your products liability insurance? Yes No
g. If yes, please attach explanation.
3.
SPECIFIED PRODUCTS & COMPLETED OPERATIONS
a. Only those products and services specified below will be considered for coverage.
Applicant acts as a/an:
Products & Services
(or specific categories)
M D R I MR
# of
Years
% of
Gross
Sales
Does ap
plicant: Products sold to:
Products & Services
(or specific categories)
Install?
Repair or
service?
D R MR C O
M -
Manufacturer
D –
Distrib
utor
R –
Retailer
I –
Importer
MR –
Manufacturers rep
C -
Consumer
O –
Other (describe)
8700 EAST NORTHSIGHT BLVD., SUITE #200 • SCOTTSDALE, ARIZONA • 85260-3669 PHONE 800-243-1782 • FAX 480-951-9722
b. Have you discontinued or are considering discontinuing any product to be covered by this insurance? Yes No
c.
Are any of your products or services known to be used in connection with aircraft/missiles/aerospace? Yes No
If yes, please attach explanatio
n.
d.
Are there any foreign manufactured products
? Yes
No
If yes, what percentage are replacement parts?
_________%
4
.
SALES
a.
Show sales for the past 5 years. (Attach a list if neces
sary.)
Year
Gross Sales Product’s Name Estimated Sales Product’s Name
Current
Year
20____
20____
20____
19____
b.
What percentage of sales are for replacement parts?
_________%
c.
Average cost of final produc
t: $
________________
d. Is original installation of products performed by your employees
? Yes
No
If no, does the installer supply parts not manufactured by you? Yes No
5.
SALES & MARKETING
a.
Total sales or receipts for all products and s
ervices:
Next
years projection 1
st
prior year Past 12 months 2
nd
prior year
$ $ $ $
b. What percentage of total sales are for replacement parts? _________%
c. What percentage of total receipts are for installation? _________%
d. Do you wish to include your customers as additional insureds with Vendors coverage? Yes No
e.
Does risk have a website? Yes No If yes, website address: _______________________________
f. If you are a distributor, are you insured by the m
anufacturer?
Yes No
g. Is your product used in connection with aircraft or aerospace? Yes No
h. How many years have you been in business under the present name
?
__________
i
.
Have any of the principals ever engaged in this or similar enterprise under a different name? Yes No
If yes, please a
ttach details.
j. Do you plan to manufacture any new products to be marketed within the next 12 months? Yes No
If yes, please attach a descri
ption.
k.
Have you ceased to manufacture any products during the past 5 years? Yes No
If yes, please attach a description by sales and year.
l.
If an
y products are accompanied by any written brochures
, labels, instructions, catalogs, service agreements, financial
data, or other written statements, please attach copies.
6.
PROCESSING & QUALITY CONTROL
a. Processing
1. Do others manufacture, assemble, package, or install products under your name or label? Yes No
If yes, please attach explanatio
n.
2. Do you manufacture, assemble, package, or install products for others under their name or label? Yes No
If yes, please attach explanatio
n.
3.
Do you manufacture the complete product? Yes
No
If no, what component parts are purchased? ________________________________________________
_________
4.
Are any parts purchased from foreign manufacturers? Yes
No
I
f yes, please describe: __________________________________________________________________________
b. Quality Control & Record Keeping
1. Do you have a quality control and testing procedure? Yes No
2. How long are quality control and testing records kept? ________________________________
3. Can you identify your product from those of competitors? Yes No
4.
Do your records show to whom and the date each product was sold? Yes No
5. Do you require certificates evidencing Products Liability Insurance from suppliers? Yes No
8700 EAST NORTHSIGHT BLVD., SUITE #200 • SCOTTSDALE, ARIZONA • 85260-3669 PHONE 800-243-1782 • FAX 480-951-9722
7. LOSS PREVENTION, LOSS CONTROL, CLAIM DEFENSE
a. Who designs your products? __________________________________________________________________________
b. Are designs reviewed, tested, and verified by others
? Yes
No
c.
Do you maintain records of changes in designs, advertisements and sales brochures? Yes No
If yes, how long? __________ year
s
d. Are all instructions, operating manuals, advertisements and warranties periodically reviewed by
Legal Counsel to avoid misunderstandings relative to product safety or intended use? Yes No
e.
Are your products designed, tested, labeled, and manufactured to meet or exceed all ap
plicable
go
vernment and industries standards? Yes No
f. Are all products UL tested and UL listed? Yes No
g. 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, please attach full details and result of such inquiry.
h.
Do you have a specific program to withdraw known or suspected defective products from the market? Yes No
i
.
Have you ever recalled or are you considering recalling any known or suspected defective product
s
f
rom the market? Yes No
j. Do you maintain and/or service the products? Yes No
If yes, please attach full details including a copy of your standard written service contract and gross receipts from this source.
(Loss Prevention, Loss Control, Claim Defense continued)
k. Do you maintain complete inventory records of shipments and/or deliveries to consignees? Yes No
l
.
Can the date of manufacture of each product be identified by the factory number stamped on it? Yes No
m. Are serial and/or batch numbers shown on the finished product and on shipment invoices? Yes No
n. Do you keep samples of products involved in your quality control procedures? Yes No
If yes, how long are samples retained? _____________________________________________________________________
o. Are any of your products subject to deterioration? Yes No
If yes, please describe and indicate period of time: ____________________________________________________________
_____________________________________________________________________________________________________
8.
GE
NERAL
a.
Are any of your products flammable or explosive? Yes
No
If yes, please a
ttach details.
b. Do you issue guarantees or warranties to purchasers? Yes No
If
yes, for what periods do you guarantee or warrant your products? ______________________________________________
Please attach full details and a copy of your form of guarantee or warranty
.
c.
Do you agree to hold dealers, distributors, subcontractors, or suppliers harmless against claims or suits
for bodily injury or property damage in connection with your products? Yes No
If yes, please attach copies of your standard forms.
Any
person who knowingly and with intent to defraud any insurance company or other person files an application for insurance
containing false information, or conceals for the purpose of misleading, information concerning any fact material thereto, commits a
fraudulent insurance act, which is a crime. This application does not bind any of the parties to complete the insurance transaction.
_______________________________ ______________________________ _________________
Applicant’s Signature
Producer’s
Signature
Date
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PRODUCT LIABILITY SUPPLEMENTAL APPLICATION (Risk Placement Services, Inc.)

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Completed 30 July 2020

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