Product Liability Form

PRODUCT LIABILITY APPLICATION FORM

1.a)  Named Insured (Include all Subsidiary Companies)

b)  Post Office Address and Principal Location :

2.             Named insured is :

 Individual       ‚ Partnership    ‚ Corporation    ‚ Joint Venture  ‚ Other                        

3.             Business of  Named insured is :

‚ Manufacturer  ‚ Distributor      ‚ Importer         ‚ Other 

4.         a)         How long has named insured been in business ? 

b)            Does applicant have a subsidiary, affiliate or representative in the USA/ Canada? (Yes/No). If yes, please give name(s) and address (es) :

 

5.         Policy period desired: From                                        to 

6.             US Products

a)             List all products manufactured sold or distributed by insured in or exported to USA/Canada and sales by product for the last 5 years as well as estimated sales for the upcoming year (Attach product brochures or other printed material-describing product).

Currency           Product            2005              2006            2007                     2008           2009        Est.2010

 (Note: Please indicate products manufactured in USA/ Canada by placing an “M” next to Product category)

b)            List all products manufactured by insured for sale in USA/Canada but not sold under their label and sales by product for the last 5 years as well as estimated sales for the upcoming year :

Currency           Product            2005              2006            2007                     2008           2009        Est.2010

(Please indicate any products actually manufactured in USA/Canada with “M”)

7.             Worldwide Sales of Products (excluding USA/ Canada)

a.1.)      Same as in 6.a. above but for products manufactured, sold or distributed outside the USA/Canada.

Currency           Product            2005              2006            2007                     2008           2009        Est.2010

                        (Please indicate any products actually manufactured in USA/Canada with “M”)

            a.2)       Please indicate approximate sales splits by country:

b.1)      Same as 6.b. above but for products sold under someone else’s label outside the USA/Canada.

Currency           Product            2005              2006            2007                     2008           2009        Est.2010

            b.2)      Please indicate approximate sales splits by country:

8.             Does applicant :

              Require “Vendors Liability” Endorsement?

Yes      No

 

If yes, please list vendor(s) and address (es)

             Enter into any hold harmless or other similar “contractual agreements”.

              Yes    No

 

If yes, please explain:

(Attach copy of such contracts, if applicable)

9.             List any product that has been discontinued or recalled in the 5 years and give reasons :

10.        Have any new products been introduced in the last 3 years?

In USA/Canada             Yes  ‚              No ‚      

Outside USA/Canada     Yes  ‚              No ‚      

If yes, list products and date of introduction:

11.         Are any new products proposed for introduction during the ensuing year?

In USA/Canada              Yes  ‚             No ‚      

Outside USA/Canada      Yes  ‚             No ‚      

If yes, list products:

12.        a) Are any product sold as component for other products ?

Yes  ‚              No ‚    

If yes, indicate likely uses:

b)    Give percentage of purchased components or parts:

c)     Are any products sold as components for or use on or with any aircraft, missiles, or watercraft?

Yes  ‚              No ‚      

If yes, give details:

13.         Are all products designed by the named insured?

Yes  ‚              No ‚      

              If not, explain:

14.          Are there or have there been any violations of the consumer product safety act or any other Federal or local legislation:

Yes  ‚              No ‚      

                          If  yes, list violations :

15.        a)         Is a written products liability loss control program in effect?

Yes  ‚              No ‚      

b)           Is there a written quality control procedure?

Yes  ‚              No ‚      

c)             Is there a written product recall plan?

Yes  ‚              No ‚      

d)            Is each product subject to and do they conform with applicable national safety standard?

Yes  ‚              No ‚      

e)             Does the insured employ the services of a testing laboratory?

Yes  ‚              No ‚      

f)              Are records keeping procedures being kept on the products?

Yes  ‚              No ‚    

             Note : Any printed material relative to question 15 must be submitted.

16.        a)         Has any carrier cancelled or refused to renew product liability coverage?

Yes  ‚              No ‚      

                        If yes, furnish details:

            b)         Who is current carrier?

17.          Is the insured aware of any product, which, because of known defects or inherent hazard, is likely to cause bodily injury or property damage?

18.          Loss experience :                                                Valuation Date

a)     Total incurred losses last 5 years :

	USA/ Canada	NON USA/Canada
2003
2004
2005
2006
2007
2008

b)    Describe all losses over US$.5,000 (paid or reserved) :

19.          Has the insured acquired any new entities within the last 5 years?

Yes  ‚              No ‚      

20.          Does the insured have a legal department?

Yes  ‚              No ‚      

 

21.          Limit of liability desired                                                               CSL (occurrence/aggregate)

 

22.          Deductible desired 

23.          Engineering :

a)    May we make a physical inspection of the named insured’s premises?

Yes  ‚              No ‚      

 

            b)    Person to contact :                                                                          Title

 

c)     Telephone  No. to Contact :  

24.          PARTICULARS OF SUPPORTING LINES       RENEWAL       ESTIMATED                      ANNUAL INSURER                                                                                  DATE                  PREMIUM

OTHER CASUALTY
WORK COMP/EMPLOYER’S  LIAB
PROPERTY
CRIME
MARINE CARGO
MARINE HULL
PERSONAL ACCIDENT
AUTOMOBILE
GROUP LIFE
GROUP BENEFITS
GROUP MEDICAL
OTHER (PLEASE SPECIFY)

We hereby declare that the statements and particulars stated in this application is true. That we have not suppressed or misstated any facts and that should any of the information given by us alter between the date of this application and the inception date of the insurance to which this application relates, we will give immediate notice thereof. We agree that this application together with any other information supplied by us shall form the basis of any contract of insurance effected thereon.

We further understand and agreed that if we misrepresent any information on this application or fail to disclose to the insurer every matter we know, or could reasonable be expected to know, that is relevant to the insurer's’decision whether to accept the risk of the insurance, and if so, on what terms, the insurer has the right to void the contract from its beginning.

Applicant’s

Signature  _________________________________________________

Date     : __________________________________________________

Name of Signatory       : ____________________________________

Title     :  __________________________________________________

(This application must be signed by an authorized Officer or Director)

Witness’ Signature       :  ____________________________________________________________

Name of  Witness         :  ____________________________________________________________

Address of Witness      :  ____________________________________________________________