Fillable RecallPROTECT - Consumer Goods & Products Application Form (Access E&S Insurance Services)

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RecallPROTECT - Consumer Goods & Products Application Form (Access E&S Insurance Services)

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Access E&S Insurance Services, Inc.
www.access-es.com
recallPROTECT+
RPCPA-06/09 Page 2
2. SALES INFORMATION
2.1 Please list the total sales figure for the past 2 years as well as the estimated sales for the
forthcoming year and indicate the approximate percentage split in sales per territory:
Year
Total Sales
USA / Canada in
%
Europe in %
Other %
2.2 Please complete the following information for the top 3 plants / facilities:
Total Sales
Products
Production
Lines
Daily
output in $
Plant I
Plant II
Plant III
2.3 Please complete the following information for the top 3 products or if coverage is product
specific, please list products to which this insurance is to apply:
Product Name/ Type
Total Sales
Average batch /
shipment size in $
Product I
Product II
Product III
3. PRODUCT INFORMATION
3.1 What percentage of your products is manufactured by an outside vendor? _________%
3.2 Please list your top 3 customers by percentage of sales:
Customer = __________________________ % of Sales = ________________
Customer = __________________________ % of Sales = ________________
Customer = __________________________ % of Sales = ________________
3.3 Please provide percentage of branded, non-branded and/or own label products:
Branded = ______% Non-Branded = ______% Own Label = ______%
3.4 Do products require external power source to operate?
□ Yes □ No
3.5 Do products require special storage facilities?
□ Yes □ No
3.6 Do products require assembly after delivery?
□ Yes □ No
recallPROTECT+
RPCPA-06/09 Page 3
3.7 Do products require installation?
□ Yes □ No
If yes, what are the average costs of installation per product?
________________
3.8 Please indicate any new products that have commenced production of have entered the public
stream of commerce within the last 12 month:
______________________________________________________________________________
4. SUPPLIER INFORMATION
4.1. Please indicate the estimated number of suppliers:
_______________
4.2. Please indicate the average length of contractual relationship with key suppliers:
_______________
4.3. Please complete in respect of your top 3 suppliers and then all other, per below:
Suppliers Name
Product(s)
Do you
Audit?
Right of
Subrogation?
□ Yes □ No
□ Yes □ No
□ Yes □ No
□ Yes □ No
□ Yes □ No
□ Yes □ No
Other
□ Yes □ No
□ Yes □ No
4.4. With what percentage of your suppliers do you have contracts that set out hold harmless and indemnity
provisions inuring to your benefit in the event of your being supplied with defect products?
________%
4.5. Are the products ordered to you specifications? □ Yes □ No
4.6. Do you require suppliers to abide by specified standards? □ Yes □ No
4.7. Are suppliers quality standards monitored? □ Yes □ No
If yes, how are standards monitored?
_________________________________________________
4.8. Are warranties obtained from all suppliers? □ Yes □ No
5. QUALITY CONTROL & TESTING
5.1
Do you have a Quality Assurance Plan in place
(if yes, please provide copy)
? □ Yes □ No
5.2
Do you have any SOPs (Standard Operating Procedures) or GMPs (Good Manufacturing Practices) in
place? □ Yes □ No
5.3
Is there are Quality Assurance Department □ Yes □ No
5.4 Is the head of the Quality Assurance Department dedicated
full time for such work?
□ Yes □ No
5.5 Is product testing utilized?
□ Yes □ No
5.6 At what point in the manufacturing process is testing performed?
□ Raw Materials □ End Product □
In Line
□ Other
_______________________
recallPROTECT+
RPCPA-06/09 Page 4
5.7
Do you use internal and/or external testing laboratory? □ Internal □ External
If external, please provide detail:
_________________________________________________
5.8 Do you retain an outside testing laboratory? □ Yes □ No
5.9
Are labels inspected?? □ Yes □ No
If yes, by whom: ______________________________________________________________
5.10
Do warning labels meet applicable industry standards?
□ Yes □ No
If no, please explain: ___________________________________________________________
6. RECALL PREPARDNESS & TRACEABILITY
6.1
Does the company have a Recall Plan in place
(if yes, please provide copy)
? □ Yes □ No
6.2
Does the company have a Crisis Management Plan in place? □ Yes □ No
(if yes, please provide copy)
6.3 Does the company have a batch coding system utilized?
□ Yes □ No
6.4
What percentage of your products can the company identify by the following
:
Product Name:
%
Day:
%
Hour:
%
Batch:
%
Shift:
%
Other:
%
6.5
To what level can you trace your products handled, manufactured or produced once they have left your
care, custody and control?
Please provide details:
____________________________________________________________
6.6
Are records kept of all shipments? □ Yes □ No
If yes, for how long:
____________________________________________________________
6.1.
Do you collect and monitor customer complains? □ Yes □ No
6.7
Who can initiate a product recall?
_________________________________________________
6.8 What is your estimate likely cost of recall?
___________________________________________
7. LOSS INFORMATION
7.1. Have you, your premises, products or processes been the subject of
recommendations or complaints made by any regulatory body, internal
or third party audit over the past year?
□ Yes □ No
If yes, please provide details: _________________________________________________
7.2.
In the last 10 years have you withdrawn or recalled any products or have you been responsible for the
costs incurred by any third party arising from the withdrawal or recall of any products regardless of any
subrogation? □ Yes □ No
If yes, please complete a recallPROTECT claims supplemental form, as attached.
recallPROTECT+
RPCPA-06/09 Page 5
7.3.
Does the company, its directors and officers have any knowledge of any current situation, fact or
circumstances which might lead to a claim under this policy? □ Yes □ No
8. LIMITS & SELF INSURED RETENTION
8.1.
Limits of Insurance requested:
________________
8.2.
Self Insured Retention Requested:
________________
9. COVERAGE
9.1.
Base coverage under this policy is Recall Costs (incl. third party recall costs) and Consultant Cost.
Please indicate what additional elements of Loss you would like to have covered:
□ Loss of Profit
□ 3 months □ 6 months □ 9 months □ 12 months
□ Rehabilitation Expenses
□ 25% □ 50% □ 75% □ 100%
□ Extra Expense
□ Replacement Costs
□ Product Extortion
□ Customer Loss of Profit
□ $250,000 □ $500,000 □ $750,000 □ $1,000,000 □ Other
_____________________
□ Customer Rehabilitation Expense
□ 25% □ 50% □ 75% □ 100%
□ Customer Extra Expense
□ Defense Costs
□ Governmental Recall
□ Adverse Publicity
□ Long Term Agreement
10. DECLARATIONS
I declare that the statements and particulars in this application are true and that no material facts have been
misstated or suppressed after enquiry. I agree that this application, together with any other information supplied
shall form the basis of any contract of insurance effected thereon. I undertake to inform the Insurers of any
material alteration to those facts occurring before completion of the contract of insurance. A material fact is one
which would influence the acceptance or assessment of the risk.
I certify that I have read and understand the applicable fraud warning set forth below:
ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD ANY INSURANCE
COMPANY OR ANOTHER 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 [NY: SUBSTANTIAL] CIVIL PENALTIES.
(Not applicable in CO, DC, FL, HI, MA, MD, NE, OH, OK, OR, VT or WA- see Additional Fraud
Notices attached hereto for these States). INSURANCE BENEFITS MAY ALSO BE DENIED.
Signature:
__________________________
Date:
_______________________
Position:
__________________________
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recallPROTECT+
RPCPA-06/09 Page 6
ADDITIONAL FRAUD NOTICES
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 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.
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 INSURER FILES A STATEMENT OF CLAIM OR AN
APPLICATION CONTAINING ANY FALSE, INCOMPLETE OR MISLEADING INFORMATION IS
GUILTY OF A FELONY IN 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 MARYLAND APPLICANTS: ANY PERSON WHO KNOWINGLY AND WILLFULLY
PRESENTS A FALSE OR FRAUDULENT CLAIM FOR PAYMENT OF A LOSS OR BENEFIT OR WHO
KNOWINGLY AND WILLFULLY 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 MASSACHUSETTS, NEBRASKA, OREGON AND VERMONT APPLICANTS: ANY
PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD ANY INSURANCE COMPANY OR
ANOTHER 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, MAY BE
COMMITTING A FRAUDULENT INSURANCE ACT, WHICH MAY BE A CRIME AND MAY SUBJECT
THE PERSON TO CRIMINAL AND CIVIL PENALTIES.
NOTICE TO OHIO APPLICANTS: 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.
NOTICE TO OKLAHOMA APPLICANTS: 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.
NOTICE TO WASHINGTON 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.
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RecallPROTECT - Consumer Goods & Products Application Form (Access E&S Insurance Services)

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Completed 8 January 2021

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