Fillable PRODUCT RECALL CLAIM SUPPLEMENT (Kinsale Insurance)

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PRODUCT RECALL CLAIM SUPPLEMENT (Kinsale Insurance)

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Page 1 of 7
PRODUCT RECALL CLAIM SUPPLEMENT
COMPLETE ONLY IF YOU HAVE EXPERIENCED PRODUCT RECALLS OR INVESTIGATIONS IN THE PAST.
COMPLETE IN ADDITION TO THE PRODUCT RECALL COVERAGE APPLICATION.
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:
Please attach copies of the following:
a) Currently valued five year loss runs
b) A copy of your current recall plan
c) For recall liability losses which were not covered by insurance, a copy of all recall liability demands
2) Recall #1
a. When was the recall announced?
b. What product(s) were recalled? Provide lot, batch, or model numbers as applicable:
c. What percentage of recalled goods were returned?
d. Who initiated the recall?
Was the recall mandatory OR voluntary?
If mandatory, please attach copies of all government authority warning letters, notices, inspection reports et cetera,
including follow-up inspection reports.
e. What were your recall expenses? $
f. Did you incur recall liability to a third party? Yes No
If yes, what value? $
APPLICANT’S INFORMATION
RECALL INFORMATION
Kinsale Insurance Company
P. O. Box 17008
Richmond, VA 23226
(804) 289-1300
www.kinsaleins.com
Page 2 of 7
g. What was the cause of your alleged product failure, contamination, defect or deficiency?
h. What actions were taken to correct your manufacturing process to prevent similar recalls going forward?
i. Did your product actually or allegedly cause general liability losses (bodily injury or Yes No
property damage) prior to being recalled?
If yes, did you have product liability insurance that responded to these claims? Yes No
Do you presently maintain a product liability insurance policy? Yes No
j. Did you experience a loss in income as a result of this recall unrelated to recall Yes No
expenses or liability (due to damaged reputation, loss of contracts, etc.)?
If yes, for low long was your profit affected?
What was your loss of income value? $
3) Recall #2
a. When was the recall announced?
b. What product(s) were recalled? Provide lot, batch, or model numbers as applicable:
c. What percentage of recalled goods were returned?
d. Who initiated the recall?
Was the recall mandatory OR voluntary?
If mandatory, please attach copies of all government authority warning letters, notices, inspection reports et cetera,
including follow-up inspection reports.
e. What were your recall expenses? $
f. Did you incur recall liability to a third party? Yes No
If yes, what value? $
g. What was the cause of your alleged product failure, contamination, defect or deficiency?
h. What actions were taken to correct your manufacturing process to prevent similar recalls going forward?
i. Did your product actually or allegedly cause general liability losses (bodily injury or Yes No
property damage) prior to being recalled?
If yes, did you have product liability insurance that responded to these claims? Yes No
Do you presently maintain a product liability insurance policy? Yes No
Page 3 of 7
j. Did you experience a loss in income as a result of this recall unrelated to recall Yes No
expenses or liability (due to damaged reputation, loss of contracts, etc.)?
If yes, for low long was your profit affected?
What was your loss of income value? $
4) Recall #3
a. When was the recall announced?
b. What product(s) were recalled? Provide lot, batch, or model numbers as applicable:
c. What percentage of recalled goods were returned?
d. Who initiated the recall?
Was the recall mandatory OR voluntary?
If mandatory, please attach copies of all government authority warning letters, notices, inspection reports et cetera,
including follow-up inspection reports.
e. What were your recall expenses? $
f. Did you incur recall liability to a third party? Yes No
If yes, what value? $
g. What was the cause of your alleged product failure, contamination, defect or deficiency?
h. What actions were taken to correct your manufacturing process to prevent similar recalls going forward?
i. Did your product actually or allegedly cause general liability losses (bodily injury or Yes No
property damage) prior to being recalled?
If yes, did you have product liability insurance that responded to these claims? Yes No
Do you presently maintain a product liability insurance policy? Yes No
j. Did you experience a loss in income as a result of this recall unrelated to recall Yes No
expenses or liability (due to damaged reputation, loss of contracts, etc.)?
If yes, for low long was your profit affected?
What was your loss of income value? $
5) Recall #4
a. When was the recall announced?
b. What product(s) were recalled? Provide lot, batch, or model numbers as applicable:
Page 4 of 7
c. What percentage of recalled goods were returned?
d. Who initiated the recall?
Was the recall mandatory OR voluntary?
If mandatory, please attach copies of all government authority warning letters, notices, inspection reports et cetera,
including follow-up inspection reports.
e. What were your recall expenses? $
f. Did you incur recall liability to a third party? Yes No
If yes, what value? $
g. What was the cause of your alleged product failure, contamination, defect or deficiency?
h. What actions were taken to correct your manufacturing process to prevent similar recalls going forward?
i. Did your product actually or allegedly cause general liability losses (bodily injury or Yes No
property damage) prior to being recalled?
If yes, did you have product liability insurance that responded to these claims? Yes No
Do you presently maintain a product liability insurance policy? Yes No
j. Did you experience a loss in income as a result of this recall unrelated to recall Yes No
expenses or liability (due to damaged reputation, loss of contracts, etc.)?
If yes, for low long was your profit affected?
What was your loss of income value? $
6) Recall #5
a. When was the recall announced?
b. What product(s) were recalled? Provide lot, batch, or model numbers as applicable:
c. What percentage of recalled goods were returned?
d. Who initiated the recall?
Was the recall mandatory OR voluntary?
If mandatory, please attach copies of all government authority warning letters, notices, inspection reports et cetera,
including follow-up inspection reports.
e. What were your recall expenses? $
f. Did you incur recall liability to a third party? Yes No
If yes, what value? $
Page 5 of 7
g. What was the cause of your alleged product failure, contamination, defect or deficiency?
h. What actions were taken to correct your manufacturing process to prevent similar recalls going forward?
i. Did your product actually or allegedly cause general liability losses (bodily injury or Yes No
property damage) prior to being recalled?
If yes, did you have product liability insurance that responded to these claims? Yes No
Do you presently maintain a product liability insurance policy? Yes No
j. Did you experience a loss in income as a result of this recall unrelated to recall Yes No
expenses or liability (due to damaged reputation, loss of contracts, etc.)?
If yes, for low long was your profit affected?
What was your loss of income value? $
Complete this section only if you have had an investigation that did not result in a recall, but did result in substantial costs
incurred to determine that a recall was not necessary
7) Investigation #1
a. Over what period did this investigation occur?
b. What product(s) were investigated? Provide lot, batch, or model numbers as applicable:
c. Why were the investigated products ultimately not recalled?
d. Were any government agencies or other legal authorities involved in the investigation, Yes No
either as investigative entities themselves, oversight, or by ordering the investigation?
If yes, please attach copies of all government authority warning letters, notices,
inspection reports et cetera, including follow-up inspection reports
e. What were the expenses of the investigation? $
f. What was the suspected cause of your alleged product failure, contamination, defect or deficiency?
g. What actions were taken to correct your manufacturing process to prevent similar production issues going forward?
PRE-RECALL INVESTIGATIONS
Page 6 of 7
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.
Page 7 of 7
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.
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:
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PRODUCT RECALL CLAIM SUPPLEMENT (Kinsale Insurance)

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Completed 31 January 2021

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