MAGL 2003 05 11 Page 1 of 4
Deerfield Insurance Company
Evanston Insurance Company
Essex Insurance Company
Markel American Insurance Company
Markel Insurance Company
Associated International Insurance
Company
APPLICATION FOR SPECIFIED PRODUCTS AND COMPLETED OPERATIONS LIABILITY
INSURANCE
Notice: If the policy for which application is made is for claims made coverage: coverage applies only to “claims” first
made during the "policy period," unless an extended reporting period is exercised.
Please read the policy carefully.
If space is insufficient to answer any question fully, attach a separate sheet.
If response is none, state NONE.
I. GENERAL INFORMATION
1. (a) Full name of Applicant:
(b) Principal business premises address:
(Street) (County)
(City) (State) (Zip)
(c) List the names of all predecessor organizations of the Applicant:
(d) Audit contact name: (e) Phone Number:
(f) Website address: (g) Date established (MM/DD/YYYY):
(h) Applicant is a:
[ ] corporation [ ] partnership [ ] sole proprietorship [ ] limited liability company (LLC) [ ] other
2. Is the Applicant controlled by, owned by, or commonly owned, affiliated or associated with any
other organization? .................................................................................................................................. Yes [ ] No [ ]
(a) If Yes, provide details.
II. SPECIFIED PRODUCTS AND COMPLETED OPERATIONS
1. Provide the following information for those products, goods and/or services the Applicant wants coverage for. Only
those products, goods and services listed below will be considered for coverage.
Products and Goods(or
specific categories)
Applicant Acts
as a(n)
M W R I MR
No. of
Years
% of
Gross
Receipts
Does Applicant
Repair or
Install? Service?
Products and
Goods sold to:
W R C O
M: manufacturer W: wholesaler R: retailer I: importer MR: manufacturer’s rep. C: consumer direct O: other (describe)
2. Total gross receipts from all products, goods and services listed in Part II, Question 1. hereinabove:
(a) Estimated annual gross receipts for the coming year: $
(b) Annual gross receipts last twelve months: Year: $
3. Does the Applicant have any operations, and/or any receipts or income from any products, goods
or services, NOT listed in Part II, Question 1. hereinabove? .................................................................... Yes [ ] No [ ]
Access E&S Insurance Services, Inc.
www.access-es.com
MAGL 2003 05 11 Page 2 of 4
If Yes,
(a) Provide a detailed explanation.
(b) Provide the following for ALL products, goods, services and operations.
(i) Estimated annual gross receipts for the coming year: $
(ii) Annual gross receipts: (1) last twelve months: Year: $ (2) 1
st
prior year: Year: $
4. Is the Applicant presently considering any change in the mix of products, goods, services and/or
operations, including adding new products, goods, services or operations, for the coming year? ........... Yes [ ] No [ ]
(a) If Yes, provide details.
5. Has the Applicant discontinued or is it considering discontinuing any product or service listed above? .. Yes [ ] No [ ]
(a) If Yes, provide details.
6. Are any of the Applicant’s products or services used in connection with aircraft/missiles/aerospace? .... Yes [ ] No [ ]
(a) If Yes, provide details.
III. PROCESSING AND QUALITY CONTROL
1. PROCESSING
(a) Do any products or ingredients or components thereof, originate from outside the United States? .. Yes [ ] No [ ]
(i) If Yes, specify:
(1) The country(ies) of origin:
(2) The name of each manufacturer, distributor or supplier:
(b) Do others manufacture, assemble, package or install products under Applicant’s name or label? ... Yes [ ] No [ ]
(i) If Yes, provide the name(s) and address(es) of contract manufacturer(s):
(c) Does the applicant manufacture, assemble, package or install products for others under their
name or label? .................................................................................................................................... Yes [ ] No [ ]
(i) If Yes, explain.
2. QUALITY CONTROL AND RECORDKEEPING
(a) Does the Applicant have a quality control and testing procedure? ..................................................... Yes [ ] No [ ]
(i) If Yes, how long does the Applicant keep quality control and testing records?
(b) Can the Applicant identify its product(s) from those of competitors? ................................................. Yes [ ] No [ ]
(c) Do all records show to whom and the date each product was sold? .................................................. Yes [ ] No [ ]
(d) Does the Applicant require certificates of insurance evidencing Products Liability Insurance
from suppliers? .................................................................................................................................... Yes [ ] No [ ]
(e) Who designs the Applicant’s products?
(f) Are product designs reviewed, tested and verified by others? ........................................................... Yes [ ] No [ ]
(g) Does the Applicant have a specific program to withdraw known or suspected defective products
from the market? ................................................................................................................................. Yes [ ] No [ ]
(h) Has the Applicant ever recalled or is it considering recalling any product? ........................................ Yes [ ] No [ ]
If Yes, attach an explanation.
(i) Have any of the Applicant’s products or ingredients or components thereof, ever been the
subject of any investigation, enforcement action, or notice of violation of any kind by any
governmental, quasi-governmental, administrative, regulatory or oversight body? ........................... Yes [ ] No [ ]
(1) If Yes, provide details.
IV. INSURANCE INFORMATION
1. (a) Limits of Liability: Indicate the limits of liability requested: $ /$
(b) Deductible: Indicate the deductible requested: $
THE COMPANY DOES NOT GUARANTEE TO OFFER ANY OF THE ABOVE LIMITS AND/OR DEDUCTIBLES.
2. Provide the following for present Product Liability Insurance: If None, check here [ ]
Insurance Limits of Deductible/ Expiration Dates Retroactive/
Company Liability SIR Premium (MM/DD/YYYY) Prior Acts Date
3. Has any insurer declined, canceled, or nonrenewed any Product Liability Insurance or any similar
insurance on behalf of any person(s) or organization(s) proposed for this insurance? ........................... [ ] Yes [ ] No
(a) If Yes, provide details.
MAGL 2003 05 11 Page 3 of 4
V. CLAIM HISTORY
1. Has any claim for Product or General Liability been made against any person(s) or organization(s) proposed
for this insurance during the last five (5) years? ...................................................................................... [ ] Yes [ ] No
If Yes, provide five (5) year loss history for all claims, including any predecessor. Attach a description of any loss
greater than $10,000.
Year No. of Claims Total Amounts Paid Amounts Reserved Total Incurred Date of Loss Info.
2. Is (are) any person(s) or organization(s) proposed for this insurance aware of any fact, incident,
circumstance, situation, condition, defect or suspected defect which may result in a Product or
General Liability claim, such that would fall under the proposed insurance? .......................................... [ ] Yes [ ] No
If Yes, provide details.
VI. ADDITIONAL INFORMATION
As part of this application attach the following: Brochures; Labels; and Instructions.
NOTICE TO THE APPLICANT - PLEASE READ CAREFULLY
No fact, incident, circumstance, situation, condition, defect or suspected defect indicating the probability of a claim or
action for which coverage may be afforded by the proposed insurance is now known by any person(s) or organization(s)
proposed for this insurance other than that which is disclosed in this application. It is agreed by all concerned that if there
is knowledge of any such fact, incident, circumstance, situation, condition, defect or suspected defect any claim
subsequently emanating therefrom shall be excluded from coverage under the proposed insurance.
This application, information submitted with this application and all previous applications related hereto and material
changes to any of the foregoing of which the underwriting manager, Company and/or affiliates thereof receives notice is
on file with the underwriting manager, Company and/or affiliates thereof and is considered physically attached to and part
of the policy if issued. The underwriting manager, Company and/or affiliates thereof will have relied upon this application
and all such attachments in issuing the policy.
For the purpose of this application, the undersigned authorized agent of the person(s) and organization(s) proposed for
this insurance declares that to the best of his/her knowledge and belief, after reasonable inquiry, the statements in this
application and in any attachments, are true and complete. The underwriting manager, Company and/or affiliates thereof
are authorized to make any inquiry in connection with this application. Signing this application does not bind the Company
to provide or the Applicant to purchase the insurance.
If the information in this application and any attachment materially changes between the date this application is signed
and the effective date of the policy, the Applicant will promptly notify the underwriting manager, Company and/or affiliates
thereof, who may modify or withdraw any outstanding quotation or agreement to bind coverage.
If the policy for which application is made is for claims made coverage, the undersigned declares that the person(s) and
organization(s) proposed for this insurance understand that coverage for which this application is made applies:
(i) Only to “claims” first made during the “policy period”; unless an extended reporting period is exercised. If an
extended reporting period is exercised, the policy shall also apply to “claims” first made during the extended reporting
period; and
(ii) Unless amended by endorsement, the limits of liability contained in the policy shall be reduced, and may be
completely exhausted by “claim expenses” and, in such event, the Company will not be liable for “claim expenses” or
the amount of any judgment or settlement to the extent that such costs exceed the limits of liability in the policy and
unless amended by endorsement, “claim expenses” shall be applied against the “deductible”.
WARRANTY
I/We warrant to the Company, that I/We understand and accept the notice stated above and that the information
contained herein is true and that it shall be the basis of the policy and deemed incorporated therein, should the Company
evidence its acceptance of this application by issuance of a policy. I/We authorize the release of claim information from
any prior insurer to the underwriting manager, Company and/or affiliates thereof.
MAGL 2003 05 11 Page 4 of 4
Note: This application is signed by undersigned authorized agent of the Applicant(s) on behalf of the Applicant(s) and its
owners, principals, partners, directors, officers and employees.
Must be signed by the owner, principal, partner, executive officer or equivalent (within 60 days of the proposed effective date).
Name of Applicant Title
Signature of Applicant Date
Notice to Applicants: 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 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.
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signature
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ZZ-50001-03 01/08
DISCLOSURE NOTICE OF TERRORISM
INSURANCE COVERAGE AND ELECTION FORM
RE: «358» «359»
Risk ID. No.: «357»
You are hereby notified that under the Terrorism Risk Insurance Act as amended, that you now have a right to
purchase insurance coverage for losses arising out of acts of terrorism, as defined in Section 102(1) of the Act: The
term “act of terrorism” means any act that is certified by the Secretary of the Treasury, in concurrence with the
Secretary of State, and the Attorney General of the United States—to be an act of terrorism; to be a violent act or an
act that is dangerous to human life, property, or infrastructure; to have resulted in damage within the United States, or
outside the United States in the case of an air carrier or vessel or the premises of a United States mission; and to have
been committed by an individual or individuals as part of an effort to coerce the civilian population of the United States
or to influence the policy or affect the conduct of the United States Government by coercion.
You should know that where coverage is provided by this policy for losses caused by certified acts of terrorism, such
losses may be partially reimbursed by the United States Government under a formula established by federal law.
However, your policy may contain other exclusions which might affect your coverage, such as an exclusion for nuclear
events. Under this formula, the United States Government generally reimburses 85% of covered terrorism losses
exceeding the statutorily established deductible paid by the insurance company providing the coverage. The premium
charged for this coverage is provided below and does not include any charges for the portion of loss covered by the
federal government under the Act.
You should also know that the Terrorism Risk Insurance Act as amended, contains a $100 billion cap that limits United
States Government reimbursement as well as insurers’ liability for losses resulting from certified acts of terrorism when
the amount of such losses in any one calendar year exceeds $100 billion. If the aggregate insured losses for all
insurers exceed $100 billion, your coverage may be reduced.
SELECTION OR REJECTION OF TERRORISM INSURANCE COVERAGE
PLEASE ENTER “X” IN ONE OF THE BOXES BELOW AND SIGN AND DATE WHERE INDICATED BELOW.
Alaska, Florida, Georgia and Oklahoma Applicants: Please be advised that in the event a policy is purchased, the
policy premium will include a 1% surcharge for Terrorism Coverage unless you elect to decline Terrorism Coverage.
You need to enter an "X” below if you wish to decline Terrorism Coverage.
I hereby elect to purchase the Terrorism Coverage required to be offered under the Act. I understand
that my policy premium will include a 3% surcharge for this coverage.
I decline to purchase the Terrorism Coverage required to be offered under the Act. I understand that my
policy will be endorsed to exclude the Terrorism Coverage required to be offered under the Act.
Name of Applicant Title (Officer, partner, etc.)
Signature of Applicant Date
SIGNING this Disclosure Notice does not bind the Applicant or the Insurer or the Underwriting Manager to complete
the insurance.
Deerfield Insurance Company
Evanston Insurance Company
Essex Insurance Company
Markel American Insurance Company
Markel Insurance Company
Associated International Insurance
Company
click to sign
signature
click to edit
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