PRODUCT
LIABILITY APPLICATION FORM
1.a) Named Insured (Include all Subsidiary
Companies)
b) Post Office Address and Principal Location
:
2.
Named
insured is :
Named
insured is :
Individual ‚
Partnership ‚ Corporation ‚
Joint Venture ‚ Other
3.
Business
of Named insured is :
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
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 :
____________________________________________________________
No comments:
Post a Comment