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

Fill Online, Printable, Fillable, Blank Product Liability Supplemental Renewal Application (Risk Placement Services, Inc.) Form

Use Fill to complete blank online RISK PLACEMENT SERVICES, INC. pdf forms for free. Once completed you can sign your fillable form or send for signing. All forms are printable and downloadable.

Product Liability Supplemental Renewal Application (Risk Placement Services, Inc.)

On average this form takes 22 minutes to complete

The Product Liability Supplemental Renewal Application (Risk Placement Services, Inc.) form is 4 pages long and contains:

  • 2 signatures
  • 10 check-boxes
  • 77 other fields

Country of origin: US
File type: PDF

Use our library of forms to quickly fill and sign your Risk Placement Services, Inc. forms online.

BROWSE RISK PLACEMENT SERVICES, INC. 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
 
A085s (05/13) Contains copyrighted material of Insurance Services Office, Inc., with its permission. Page 1 of 4
Product Liability Supplemental Renewal Application
All questions must be answered in full. If necessary, attach a separate sheet of paper with complete details.
Application must be signed and dated by the applicant.
Applicant’s Name
Agent
Applicant Mailing Address
Applicant’s Phone Number
Web Address
Inspection Contact
Proposed Policy Period to Phone Number for Inspection Contact
UNDERWRITING INFORMATION
1. Description of any changes in operations or products manufactured, distributed or sold during the past year:
2. Description of any products discontinued during the past year:
3. Description of all acquisitions completed in the past year:
4. Description of any new products manufactured or sold during the last year:
5. Have you changed any supply vendors during the past year? ......................................................................... Yes No
If yes, what product, part(s) are affected?
Provide name of company and country of manufacture:
6. Do you import any products or components? .................................................................................................... Yes No
If yes, what products or components are imported and from which countries?
7. Have you attained ISO 9002, QS 9000 or similar Certification? ....................................................................... Yes No
8. Do you plan to introduce any new products during the year? ........................................................................... Yes No
If yes, describe:
9. Have you voluntarily or involuntarily recalled any known or suspected defective products
from the market during the past year? ...............................................................................................................
Yes No
If yes, describe. ______________________________________________________________________________
10. Are you considering recalling any known or suspected defective products from the market? ........................... Yes No
If yes, describe. ______________________________________________________________________________
11. 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.
12. 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.
13. Are you aware of any study, analysis or trial conducted or being conducted by or on behalf of
any governmental agency or industry regulatory body to examine the safety of your product: .........................
Yes No
Agency Name:
Address:
Contact Name:
Phone:
Fax:
Email:
A085s (05/13) Contains copyrighted material of Insurance Services Office, Inc., with its permission. Page 2 of 4
UNDERWRITING INFORMATION (Continued)
14. Total Annual
Gross Sales
Y
EARS
S
ALES
UNITED STATES FOREIGN* TOTAL
UPCOMING YEAR (ESTIMATE)
to
CURRENT YEAR
to
*If any foreign sales, list countries where your product is sold:
LOSS INFORMATION (Update to include any newly reported losses that occurred in prior years or changes to paid or reserve
amounts for previously reported loses)
LOSS HISTORY (LAST FIVE YEARS)
DATE OF LOSS TYPE OF LOSS DESCRIPTION OF LOSS AMOUNT PAID RESERVE
PLEASE READ BELOW AND COMPLETE SIGNATURE BLOCK ON LAST PAGE
I have reviewed this application for accuracy before signing it. As a condition precedent to coverage, I hereby state that the
information contained herein is true, accurate and complete and that no material facts have been omitted, misrepresented or
misstated. I know of no other claims or lawsuits against the applicant and I know of no other events, incidents or occurrences
which might reasonably lead to a claim or lawsuit against the applicant. I understand that this is an application for insurance
only and that completion and submission of this application does not bind coverage with any insurer.
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 – FOR THE STATE(S) OF:
Alabama, Arkansas, Connecticut, Delaware, District of Columbia, Georgia, Idaho, Illinois, Indiana, Iowa, Kentucky,
Louisiana, Maryland, Massachusetts, Michigan, Minnesota, Mississippi, Missouri, Montana, Nebraska, Nevada, New
Hampshire, North Carolina, North Dakota, Rhode Island, South Carolina, South Dakota, Texas, Utah, Vermont, West
Virginia, Wisconsin, Wyoming:
NOTICE: In some states, any person who knowingly (For Maryland add: or willfully) presents a false or fraudulent claim for
payment of a loss or benefit or knowingly (For Maryland add: or willfully) presents false information in an application for
insurance is guilty of a crime and may be subject to (For Alabama add: restitution,) fines and confinement in prison (For
Alabama add: or any combination thereof).
Maine, Tennessee, Virginia, Washington:
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 a denial of insurance benefits.
Alaska
A person who knowingly and with intent to injure, defraud, or deceive an insurance company files claim containing false,
incomplete, or misleading information may be prosecuted under state law.
Arizona
For your protection Arizona law requires the following statement to appear on this form. Any person who knowingly presents a
false or fraudulent claim for payment of a loss is subject to criminal and civil penalties.
A085s (05/13) Contains copyrighted material of Insurance Services Office, Inc., with its permission. Page 3 of 4
California
For your protection, California law requires that you be made aware of the following: Any person who knowingly presents false
or fraudulent claim for the payment of a loss is guilty of a crime and may be subject to fines and confinement in state prison.
Colorado
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 policyholder or claimant for the purpose of defrauding or attempting to defraud the
policyholder or claimant with regard to a settlement or award payable from insurance proceeds shall be reported to the
Colorado division of insurance within the department of regulatory agencies.
Florida
Any person who knowingly and with intent to injure, defraud or deceive any insurer files a statement of claim or an application
containing any false, incomplete, or misleading information is guilty of a felony of the third degree.
District of Columbia
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.
Hawaii
Intentionally or knowingly misrepresenting or concealing a material fact, opinion or intention to obtain coverage, benefits,
recovery or compensation when presenting an application for the issuance or renewal of an insurance policy or when
presenting a claim for the payment of a loss is a criminal offense punishable by fines or imprisonment, or both.
Idaho
Any person who knowingly, and with intent to defraud or deceive any insurance company, files a statement of claim containing
any false, incomplete, or misleading information is guilty of a felony.
Indiana
Any person who knowingly and with intent to defraud an insurer files a statement of claim containing any false, incomplete, or
misleading information commits a felony.
Kansas
Any person who commits a fraudulent insurance act is guilty of a crime and may be subject to restitution, fines and
confinement in prison. A fraudulent insurance act means an act committed by any person who, knowingly and with intent to
defraud, presents, causes to be presented or prepares with knowledge or belief that it will be presented to or by an insurer,
purported insurer or insurance agent or broker, any written statement as part of, or in support of, an application for insurance,
or the rating of an insurance policy, or a claim for payment or other benefit under an insurance policy, which such person
knows to contain materially false information concerning any material fact thereto; or conceals, for the purpose of misleading,
information concerning any fact material thereto.
Minnesota
Any person who files a claim with intent to defraud or help commit a fraud against an insurer is guilty of a crime.
New Hampshire
Any person who, with a purpose to injure, defraud or deceive any insurance company, files a statement of claim containing
any false, incomplete, or misleading information is subject to prosecution and punishment for insurance fraud, as provided in
RSA 638:20.
New Jersey
Any person who includes any false or misleading information on an application for an insurance policy is subject to criminal
and civil penalties.
New Mexico
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.
New York
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 shall also be subject to a civil
penalty not to exceed five thousand dollars and the stated value of the claim for each such violation.
Ohio
Any person who, with intent to defraud or knowing that he 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.
Oklahoma
WARNING – Any person who knowingly, and with intent to injure, defraud or deceive any insurer, makes any claim for the
proceeds of an insurance policy containing any false, incomplete or misleading information is guilty of a felony.
A085s (05/13) Contains copyrighted material of Insurance Services Office, Inc., with its permission. Page 4 of 4
Oregon
Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents
materially false information in an application for insurance may be guilty of a crime and may be subject to fines and
confinement in prison. In order for us to deny a claim on the basis of misstatements, misrepresentations, omissions or
concealments on your part, we must show that:
A. The misinformation is material to the content of the policy;
B. We relied upon the misinformation; and
C. The information was either:
1. Material to the risk assumed by us; or
2. Provided fraudulently.
For remedies other than the denial of a claim, misstatements, misrepresentations, omissions or concealments on your part
must either be fraudulent or material to our interests. With regard to fire insurance, in order to trigger the right to remedy,
material misrepresentations must be willful or intentional. Misstatements, misrepresentations, omissions or concealments on
your part are not fraudulent unless they are made with the intent to knowingly defraud.
Pennsylvania
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 such person to criminal
and civil penalties.
Producer’s Signature
Date
Applicant's Signature
Date
click to sign
signature
click to edit
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 Liability Supplemental Renewal Application (Risk Placement Services, Inc.)

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 30 July 2020

Message

View Audit Log
Print With Audit Log
Duplicate Document