Fillable PRODUCT RECALL SUPPLEMENTAL APPLICATION (Kinsale Insurance)

Fill Online, Printable, Fillable, Blank PRODUCT RECALL SUPPLEMENTAL APPLICATION (Kinsale Insurance) Form

Use Fill to complete blank online KINSALE INSURANCE pdf forms for free. Once completed you can sign your fillable form or send for signing. All forms are printable and downloadable.

PRODUCT RECALL SUPPLEMENTAL APPLICATION (Kinsale Insurance)

On average this form takes 43 minutes to complete

The PRODUCT RECALL SUPPLEMENTAL APPLICATION (Kinsale Insurance) form is 6 pages long and contains:

  • 1 signature
  • 39 check-boxes
  • 150 other fields

Country of origin: US
File type: PDF

Use our library of forms to quickly fill and sign your Kinsale Insurance forms online.

BROWSE KINSALE INSURANCE FORMS

Related forms
Fill has a huge library of thousands of forms all set up to be filled in easily and signed.
Fill in your chosen form
Sign the form using our drawing tool
Send to someone else to fill in and sign.
find another form
 
Page 1 of 6
PRODUCT RECALL SUPPLEMENTAL APPLICATION
COMPLETE IN ADDITION TO ACORD APPLICATIONS.
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:
2) Current Carrier Information:
Carrier:
Recall Expense?
Yes No
Recall Liability?
Yes No
Cutoff Date:
Deductible:
Premium:
Offering renewal?
Yes No
Please attach copies of the following:
a) Currently valued five-year General Liability/Product Liability and Recall loss runs, and loss details for any
recalls outside of coverage history. If you have had a recall, complete the Kinsale Product Recall Claim
Supplement and include copies of all governmental agency documents for all recall claims and any applicable
court documents
b) Product brochure, catalog, or marketing materials if a website is not available
c) Current policy declarations page for cutoff date (if applicable)
d) Copy of your current recall plan, quality assurance/product testing protocols and methods, HACCP plan,
SSOP/GMP plans, etc. as applicable to your operations
3) Mailing address:
Address:
City: State: Zip Code:
4) Premise address:
Address:
City: State: Zip Code:
Kinsale Insurance Company
P. O. Box 17008
Richmond, VA 23226
(804) 289-1300
www.kinsaleins.com
Page 2 of 6
5) Years you have been in operation and selling products of the type for which you are seeking coverage:
6) Total sales of products for which coverage is being sought for the coming year: $
7) Projected number of units sold for which coverage is being sought for the coming year:
8) If you are seeking recall coverage for specific products only, please list them:
9) Have you ever had a product recall? If yes, please complete and attach the Kinsale Yes No
Recall Claim Supplement and copies of all pertinent government documents.
10) Are any of your products presently under investigation, by yourself or any other entity or Yes No
government authority, for a possible defect, flaw, contamination or other issue which may give
rise to a product recall? If yes please attach details.
a. Have you had any customer complaints about specific product(s)? If yes, attach details. Yes No
11) Do you carry General Liability (GL) or Products/Completed Operations (PRCO) liability insurance Yes No
for your products?
12) Have you had any product liability claims within the last five years? Yes No
a. If yes, how many?
b. If you have had multiple claims, did they involve the same or very similar products? Yes No
c. Has any product design changed as a result of claims? Yes No
13) What type of product are you selling? Check all that apply:
Consumable Goods (food, beverage, etc. - Cosmetics/Nutraceuticals please complete Life Sciences Recall Application)
Component Parts (automobile, machinery/equipment, aircraft, etc. parts)
Consumer Goods (electronics, clothing, toys, sporting goods, etc.)
14) What is the nature of your sales? Check all that apply:
Direct to consumer
Business to Business – Complete/Packaged Goods for Sale
Business to Business – Complete/Packaged Goods for Business Use
Business to Business – Ingredients
Business to Business – Parts and Components
15) If you are not seeking coverage for a specific product(s) identified in 8) only, please complete the below for your
top five products:
Product
Total sales
Average lot/batch size
Percentage of sales
16) How many products are in a normal batch or lot number?
Page 3 of 6
17) In addition to your internal testing/quality control measures, are your products tested by any Yes No
independent 3rd parties or government authorities?
a. List testing agency or firm(s):
b. How frequently is this testing done?
18) Do you outsource any parts, components, or ingredients for your product? Yes No
a. If yes, are any parts, components, or ingredients imported? Yes No
b. If yes to a., what percent? %
c. Do you track or maintain records of lot or batch numbers of sourced materials and the Yes No
corresponding lot or batch of your products in which they have been incorporated?
d. Have any of your suppliers ever notified you of a recall? Yes No
e. Do any suppliers grant you indemnification for product recall? Yes No
f. If yes to e., do you collect certificates of insurance (COIs) confirming AI status? Yes No
19) If you are selling business to business, do you provide any of your customers indemnification Yes No
or hold harmless agreements relating to product recall?
20) How frequently are all processing, production, packing or other handling lines:
a. Cleaned?
b. Maintained/Mechanically Serviced?
c. Shut down for deep sanitization?
21) Do you handle or process any common allergens (nuts, dairy, soy, etc.) in any of your facilities? Yes No
a. If yes, does your labeling notify of possible contamination? Yes No
b. Do you source from suppliers who may reasonably be assumed to handle common allergens? Yes No
22) Are your products subject to any government agency or authority labeling regulations? Yes No
23) Please check the federal agencies’ rules and authority under which your products are subject to regulation:
Food and Drug Administration (FDA) United States Department of Agriculture (USDA)
Consumer Product Safety Commission (CPSC) State-specific Cannabis Regulatory Body
Bureau of Alcohol, Tobacco, and Firearms (ATF) Other:
24) Do you utilize any of the following sanitary preparation methods? Check all that apply:
Pasteurization Ultra-High Pressure Processing
Ultra-Violet (UV) Irradiation Fully cooked foods only
Irradiation (other than UV) Other:
25) What is the shelf life of your products?
a. Are products sold frozen, with the intent to remain so until use? Yes No
b. If your product is an ingredient/additive of another company’s product, does the final Yes No
product have the same shelf life as your product? If no, please clarify:
26) Have you ever been subject to a criminal tampering/intentional adulteration incident? Yes No
If yes, please attach details and a copy of any applicable police reports.
27) Have you ever received a violation notice from the FDA or other similar agency that did not Yes No
result in a recall? If yes, please attach a copy as well as any follow up reports, re-inspections,
Page 4 of 6
and the corrective action plan implemented.
28) Do you do your own research and development or engineering? Yes No
a. If no, are blueprints or designs supplied by your customer(s)? Yes No
b. Please describe the qualifications of and any professional designations held by the person or persons
responsible for product engineering or design:
29) Do you track reported failures or other customer complaints? Yes No
a. If yes, how long are these records retained?
b. What is the typical post-handover failure rate for your products?
30) Please check the federal agencies’ rules and authority under which your products are subject to regulation:
Consumer Product Safety Commission (CPSC) Federal Aviation Administration (FAA)
US Coast Guard (USCG) National Highway Traffic Safety Administration (NHTSA)
Department of Transportation (DOT) US Chemical Safety & Hazard Investigation Board
Environmental Protection Agency (EPA) Other:
31) Do you have ISO 9001, CSA, CE, and/or UL Certification? Yes No
Please list Certifications:
32) What is the expected operational life of your products?
33) If your product is found to be defective, can it easily be removed from the device which is it a Yes No
component part of?
34) If you sell products used in aviation, have any of your products been the determined or Yes No
suspected cause of a fault that resulted in a grounding?
a. If yes, did the grounding lead to a recall of your products? Yes No
b. Approximately how many aircraft or flights were impacted?
35) Are the end users of your product typically children under the age of 13? Yes No
If yes, under the age of 3? Yes No
36) Do any of your products contain Lithium Ion (Li-ion) or Lithium Polymer (Li-Po) batteries? Yes No
a. If yes, list manufacturers:
b. If yes, are all batteries UL stamped? Yes No
37) Please check the federal agencies’ rules and authority under which your products are subject to regulation:
Consumer Product Safety Commission (CPSC) Federal Aviation Administration (FAA)
Department of Transportation (DOT) National Highway Traffic Safety Administration (NHTSA)
Environmental Protection Agency (EPA) US Chemical Safety & Hazard Investigation Board
US Coast Guard (USCG) Other:
38) Are your products subject to any American Society for Testing and Materials (ASTM) voluntary Yes No
standards?
a. If yes, are you compelled by law to meet these standards? Yes No
b. If no to a., do you meet them regardless? Yes No
Page 5 of 6
39) Do you have ISO 9001, CSA, CE, and/or UL Certification? Yes No
Please list Certifications:
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.
Page 6 of 6
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:
click to sign
signature
click to edit
Download
Save PDF to desktop
Email
Email completed PDF
Send for Signing
Email for others to sign
Print
Print document
Choose a Field
Click on a field and
select the person that should complete it
Want to add a signature?
You can add a signature field
and assign it to someone else
to sign
Choose a Field
Click on a field and
select the person that should complete it

PRODUCT RECALL SUPPLEMENTAL APPLICATION (Kinsale Insurance)

This document is locked as it has been sent for signing.

You have successfully completed this document.

Other parties need to complete fields in the document. You will recieve an email notification when the document has been completed by all parties.

This document has been signed by all parties.

Completed 31 January 2021

Message

View Audit Log
Print With Audit Log
Duplicate Document