Fillable Product Liability Application (Risk Placement Services, Inc.)

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Product Liability Application (Risk Placement Services, Inc.)

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S379 (04/05) Page 1 of 4
Agent Name: Contact:
Agent Address: Phone #
Product Liability Application
All questions must be answered in full. Application must be signed and dated by the applicant.
Applicant’s Name
Agent
Applicant’s Phone Number
Web Address
Applicant Mailing Address
Inspection Contact
Proposed Policy Period to Phone Number for Inspection Contact
Applicant is Individual Partnership Corporation Joint Venture Other
Location #1
Location #2
Location #3
UNDERWRITING INFORMATION
1. Business of Applicant is: Manufacturer Distributor Direct Importer Broker Other (Describe)
2. Description of operations:
3. Years in business:
4. Description of all acquisitions completed in the last five years:
5. Description of all discontinued products and historical sales for each:
SALES
6. Total Annual
Gross Sales
YEARS
UNITED STATES FOREIGN* TOTAL
UPCOMING YEAR (ESTIMATE)
to
CURRENT YEAR
to
FIRST PRIOR YEAR
to
SECOND PRIOR YEAR
to
THIRD PRIOR YEAR
to
FOURTH PRIOR YEAR
to
*If any foreign sales, list countries where your product is sold:
S379 (04/05) Page 2 of 4
UNDERWRITING INFORMATION (Continued)
7. If you distribute products manufactured by others:
a. Do you directly import any products? .......................................................................................................
Yes No
If yes, describe products and provide corresponding sales and countries of origin.
b. Do you obtain Certificates of Product Liability Insurance from each of your manufacturers/suppliers? ... Yes No
If yes, what are the minimum limits of insurance required?
c. Are you included as an Additional Insured-Vendor under each manufacturer’s / supplier’s Product Liability
insurance? ................................................................................................................................................ Yes No
8. If you contract the manufacturing of your product to others, do you have a formal written agreement with your sub-
manufacturers? ................................................................................................................................................ Yes No
If yes, attach those sections of the agreement(s) pertaining to Product Liability and Product Liability insurance.
9. Do you obtain Certificates of Insurance from all suppliers evidencing Product Liability insurance? ................ Yes No
If yes, minimum limits of insurance required?
10. Do you or others on your behalf install, service, repair or maintain your products? ........................................ Yes No
If yes, attach full details including a copy of your standard written contract and estimate the percentage of sales
generated by these operations.
11. Do you maintain formal written quality control and testing procedures? ......................................................... Yes No
12. How long are quality control and testing records kept?
13. Can you identify your product from those of competitors? ............................................................................. Yes No
14. Do you maintain records of the following:
a) When and where your product was manufactured? .................................................................................... Yes No
b) To whom your product was sold and the date of sale? ............................................................................... Yes No
c) Who supplied the parts and/or supplies going into the product? ................................................................. Yes No
d) Changes in design? ....................................................................................................................................
Yes No
e) Changes in advertising material? ................................................................................................................ Yes No
If yes, how long do you maintain the records?
15. Who designs your products?
16. Are designs reviewed, tested and verified by others? ..................................................................................... Yes No
If yes, by whom?
List their credentials:
17. Are all warning labels and instructions for use reviewed by outside counsel? ............................................... Yes No
18. Are your products subject to any government or industry standards?.............................................................. Yes No
If yes, are your products in full compliance? .................................................................................................. Yes No
Describe the standards and the documentation:
19. Have you attained ISO 9002, QS 9000 or similar Certification? ...................................................................... Yes No
20. Do you offer training or instruction on the use of your products? .................................................................... Yes No
If yes, do you certify the trainees? ................................................................................................................... Yes No
21. Do you have a formal written products recall procedure? ............................................................................... Yes No
If yes, attach a copy.
S379 (04/05) Page 3 of 4
UNDERWRITING INFORMATION (Continued)
22. Have you voluntarily or involuntarily recalled, or are you considering recalling, any known or suspected defective products
from the market? ............................................................................................................................................
Yes No
If yes, describe.
23. Are you aware of any incident, condition, circumstance, defect or suspected defect in any product or work, which may
result in a claim or claims against you that are not listed above? ................................................................... Yes No
If yes, attach an explanation.
24. Are you aware of any complaint or notice filed in the last three years with any governmental agency or industry regulatory
body including but not limited to the U.S. Consumer Product Safety Commission concerning your product?
.........................................................................................................................................................................
Yes No
If yes, attach an explanation.
25. Desired Limits. Deductible/SIR.
26. Current Carrier Information
CARRIER LIMITS DEDUCTIBLE/SIR RATE PREMIUM
Coverage Form: Occurrence Claims Made, Retro Date:
Is current carrier offering renewal? .................................................................................................................. Yes No
PRIOR CARRIER HISTORY & LOSS INFORMATION
PRIOR CARRIERS (LAST THREE YEARS):
YEAR CARRIER POLICY NUMBER LIMITS PREMIUM
LOSS HISTORY (LAST FIVE YEARS)
DATE OF LOSS TYPE OF LOSS DESCRIPTION OF LOSS AMOUNT PAID RESERVE
S379 (04/05) Page 4 of 4
Has the applicant been cancelled or non-renewed in the last three years? ............................................................
Yes No
If yes, Explain.
This application shall not be binding unless and until confirmation by the Company or its duly appointed representatives has
been given, and that a policy shall be issued and a payment shall be made, and then only as of the commencement date of
said policy and in accordance with all terms thereof. The said applicant hereby covenants and agrees that the foregoing
statements and answers are a full and true statement of all the facts and circumstances with regard to the risk to be insured,
and the same are hereby made the basis and conditions of the insurance and a warranty on the part of the Insured.
Producer’s Signature Date Applicant's Signature Date
IMPORTANT NOTICE
As part of our underwriting procedure, a routine inquiry may be made to obtain applicable information concerning character,
general reputation, personal characteristics, and mode of living. Upon written request, additional information as to the nature
and scope of the report, if one is made, will be provided.
FRAUD STATEMENT
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.
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Product Liability Application (Risk Placement Services, Inc.)

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Completed 30 July 2020

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