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

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Products Liability Application (Risk Placement Services, Inc.)

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WHI-APP-119 (8-02) Page 1 of 4
6263 North Scottsdale Road, Suite 240 • Scottsdale, Arizona 85250
1-800-873-9442 • Fax (480) 596-7859
Products Liability Application
Applicant’s Name __________________________________________ Agent Name ______________________________________
Mailing Address __________________________________________ Address ______________________________________
__________________________________________ ______________________________________
Location __________________________________________ PROPOSED EFFECTIVE DATE:
__________________________________________ From
To
12:01 A.M., Standard Time at the address of the Applicant.
Applicant is: T Individual T Corporation T Partnership T Joint Venture T Other (Specify): ____________
LIMITS OF LIABILITY REQUESTED
COVERAGE EACH OCCURRENCE AGGREGATE
COMBINED SINGLE LIMIT $ ,000 $ ,000
1. Deductible desired: __________________________________________________________________________________________________
2. Completely describe product(s) to be specifically insured:________________________________________________________
________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________
3. Location(s) at which product(s) are manufactured by the Applicant: _____________________________________________
________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________
4. Location(s) from which product(s) are distributed directly by the Applicant:_____________________________________
________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________
5. Of what materials or components is each product principally composed? _______________________________________
________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________
6. Do you compound ingredients?........................................................................................................... Yes No
Do you package the product? .................................................................................................................. Yes No
7. Are all products sold under your label? .............................................................................................. Yes No
If not, describe:
________________________________________________________________________________________________________
WHI-APP-119 (8-02) Page 2 of 4
________________________________________________________________________________________________________________________
8. Do you manufacture the complete product? ....................................................................................... Yes No
If no, what component parts are purchased?___________________________________________________________________________
9. Total number of employees: ................................................................................................................. Yes No
10. Is any of your work subcontracted to others?..................................................................................... Yes No
If so, state type and percentage: _______________________________________________________________________________________
11. Are any parts purchased from foreign manufacturers?...................................................................... Yes No
If yes, describe:________________________________________________________________________________________________________
12. Do you assemble the product?............................................................................................................. Yes No
13. Has the product been tested by Underwriters Laboratories?............................................................. Yes No
Is it UL listed?.......................................................................................................................................... Yes No
14. W hat percentage of sales are for replacement parts? ______________________________________________________________
15. Has your product ever been subject to any inquiry or investigation by any governmental agency
concerning the efficiency, adequacy of labeling, hazardous contents or safety? ............................ Yes No
If yes, attach full details and result of such inquiry. ____________________________________________________________________
16. Do you maintain and/or service the products? ................................................................................... Yes No
a. If yes, attach full details including a copy of your standard written service contract and gross re-
ceipts from this source.
b. Do you maintain complete inventory records of shipments and/or deliveries to consignees? ............. Yes No
c. Can the date of manufacture of each product be identified by the factory number stamped on it? ..... Yes No
d. Have you ever recalled any of your products for any reason? If yes, attach details........................... Yes No
e. Are serial and/or batch numbers shown on the finished product and on shipment invoices? .............. Yes No
f. Do you keep samples of products involved in your quality control procedures? ................................. Yes No
If yes, how long are samples retained?
____________________________________________________________________________
g. Do you have a product recall plan? If yes, attach description............................................................ Yes No
17. Is original installation of products performed by your employees? .................................................. Yes No
If no, does the installer supply parts not manufactured by you? ............................................................... Yes No
18. Are any of your products subject to deterioration? ............................................................................ Yes No
If yes, describe and indicate period of time:____________________________________________________________________________
19. Are any of your products inflammable or explosive? ......................................................................... Yes No
If yes, attach details.___________________________________________________________________________________________________
20. Do you issue guarantees or warranties to purchasers? ..................................................................... Yes No
If so, for what periods do you guarantee or warrant your products? ____________________________________________________
Attach full details and copy of your form of guarantee or warranty.
21. Do you agree to hold dealers, distributors, subcontractors or suppliers harmless against claims
or suits for bodily injury or property damage in connection with your products?........................... Yes No
If yes, attach copies of your standard forms.
WHI-APP-119 (8-02) Page 3 of 4
22. Are any of the above dealers, etc. affiliated with you? ....................................................................... Yes No
If yes, explain: _________________________________________________________________________________________________________
23. If you are a distributor, are you insured by the manufacturer?.......................................................... Yes No
24. Is your product used by Aircraft or Aerospace Industry?................................................................... Yes No
25. How many years have you been in business under the present name?............................................ Yes No
Have any of the principals ever engaged in this or similar enterprises under a different name? ............... Yes No
If yes, attach details.
26. Do you plan to manufacture any new products to be marketed within the next 12 months? .......... Yes No
If yes, attach description.
27. Have you ceased to manufacture any products during the past 5 years?......................................... Yes No
If yes, attach description and sales by year.
28. If any products are accompanied by any written brochure, labels, instructions or other written statements,
attach copies.
29. Show sales for five (5) years: (Attach list if necessa
ry)
YEA
R GROSS SALES PRODUCT NAME
1.
2.
3.
4.
5.
30. What is estimated sales for this year? ______________________________________________________________________________
Give claims history in following form or equivalent (5 years) (Amounts shown should be from the ground up)
CLAIMS PAID RESERVES OPEN
YEAR
NUMBER AMOUNT NUMBER AMOUNT
INSURER’S NAME
1.
2.
3.
4.
5.
31. Has any insurer ever cancelled or refused to issue or renew your products liability insurance?
(Not applicable in Missouri)...................................................................................................................... Yes No
If yes, why?
____________________________________________________________________________________________________________
This application does not bind the applicant nor the Company to complete the insurance, but it is agreed that the informa-
tion contained herein shall be the basis of the contract should a policy be issued.
WHI-APP-119 (8-02) Page 4 of 4
APPLICABLE IN THE STATE OF NEW YORK:
Any person who knowingly and with intent to defraud any insurance company or other person files an application for in-
surance or statement of claim containing any materially false information, or conceals for the purpose of misleading, in-
formation 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.
FRAUD WARNING:
Any person who knowingly and with intent to defraud any insurance company or other person files an application for in-
surance or statement of claim containing any materially false information or conceals for the purpose of misleading, in-
formation concerning any fact material thereto commits a fraudulent insurance act, which is a crime and subjects such
person to criminal and civil penalties.
APPLICANT’S SIGNATURE: _________________________________________________ DATE: __________________________________
AGENT NAME: __________________________________________________ AGENT LICENSE NUMBER:_________________________
(Applicable to Florida Agents Only.)
NAME AND PHONE NUMBER OF INDIVIDUAL TO CONTACT FOR INSPECTION/AUDIT:______________________________
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 requests, additional informa-
tion
as to the nature and scope of the report, if one is made, will be provided.
ANSWER ALL QUESTIONS— IF THEY DO NOT APPLY, INDICATE NOT APPLICABLE
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Products Liability Application (Risk Placement Services, Inc.)

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Completed 30 July 2020

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