What is your first name? *
What is your last name? *
What is your email address? *
What is your phone number? *
What is the full legal name of the business? (The phrase "the business" used throughout this form refers to the applicant.) *
Does the business have another name? (ie. DBA)
What other name does the business operate under?
What is the mailing address for the business? *
Is the physical location address the same as the mailing address? *
What is the main physical location address for the business? *
What is the website address for the business?
What legal entity type does the business have? *
Please enter the business's legal entity type. *
What is the business's Federal Employer Identification Number (FEIN)? *
Please select the classification that fits this business. *
How many years has the business been operating? *
Please enter a description of the business's operations. *
Does the business have Product Liability insurance in place currently? *
What is the name of the current insurance carrier?
Please provide the following information about your current product liability insurance policy.
What type of coverage form is your current insurance policy?
Is the current carrier offering to renew the policy? *
Is there a third party requiring you to provide evidence of your product liability insurance coverage?
Please provide details of the insurance requirements the third party is requesting. *
What date would you like this coverage to commence? *
MM slash DD slash YYYY
Has the business ever discontinued any products? *
Please provide a description of all discontinued products and historical sales for each.
Has the business completed any acquisitions in the past five years? *
Please provide a description of all acquisitions completed in the last five years.
Upcoming Year Annual Sales (Estimate)
Answer the questions below to provide sales details and projections for the upcoming year.
Please enter a start date for your sales estimate. *
MM slash DD slash YYYY
Please enter an end date for your sales estimate. *
MM slash DD slash YYYY
Please select the countries where the business sells product. *
Please enter the estimated sales for the United States. *
Please enter the estimated sales for Canada. *
Please enter the estimated sales for the U.K., Ireland, and Australia. *
Please enter the estimated sales for all other countries. *
This field shows the business's total worldwide sales estimate. (Calculates automatically)
Current Year Annual Sales
Please enter a start date for the current year sales for the business. *
MM slash DD slash YYYY
Please enter an end date for current year sales for the business. *
MM slash DD slash YYYY
Please select the countries where the business sells product. *
Please enter the current year sales for the United States. *
Please enter the current year sales for Canada. *
Please enter the current year sales for the U.K., Ireland, and Australia. *
Please enter the current year sales for all other countries. *
This field shows the business's total worldwide sales. (Calculates automatically)
First Prior Year Annual Sales
Please enter a start date for the first prior year sales for the business. *
MM slash DD slash YYYY
Please enter an end date for first prior year sales for the business. *
MM slash DD slash YYYY
Please select the countries where the business sells product. *
Please enter the current year sales for the United States. *
Please enter the current year sales for Canada. *
Please enter the current year sales for the U.K., Ireland, and Australia. *
Please enter the current year sales for all other countries. *
This field shows the business's total worldwide sales. (Calculates automatically)
Second Prior Year Annual Sales
Please enter a start date for the second prior year sales for the business. *
MM slash DD slash YYYY
Please enter an end date for second prior year sales for the business. *
MM slash DD slash YYYY
Please select the countries where the business sells product. *
Please enter the second prior year sales for the United States. *
Please enter the second prior year sales for Canada. *
Please enter the second prior year sales for the U.K., Ireland, and Australia. *
Please enter the second prior year sales for all other countries. *
This field shows the business's total worldwide sales. (Calculates automatically)
Third Prior Year Annual Sales
Please enter a start date for the third prior year sales for the business. *
MM slash DD slash YYYY
Please enter an end date for third prior year sales for the business. *
MM slash DD slash YYYY
Please select the countries where the business sells product. *
Please enter the third prior year sales for the United States. *
Please enter the third prior year sales for Canada. *
Please enter the third prior year sales for the U.K., Ireland, and Australia. *
Please enter the third prior year sales for all other countries. *
This field shows the business's total worldwide sales. (Calculates automatically)
Fourth Prior Year Annual Sales
Please enter a start date for the fourth prior year sales for the business. *
MM slash DD slash YYYY
Please enter an end date for fourth prior year sales for the business. *
MM slash DD slash YYYY
Please select the countries where the business sells product. *
Please enter the fourth prior year sales for the United States. *
Please enter the fourth prior year sales for Canada. *
Please enter the fourth prior year sales for the U.K., Ireland, and Australia. *
Please enter the fourth prior year sales for all other countries. *
This field shows the business's total worldwide sales. (Calculates automatically)
Distribution-Manufacturing Information
Does the business distribute products manufactured by others? *
Does the business directly import the final product from a foreign company?
Does the business contract the manufacturing or assembly of a final product to others?
Is any manufacturing or assembly performed by a foreign company?
Do you obtain Certificates of Product Liability Insurance from each of your manufacturers/suppliers?
Please enter the minimum limits of insurance you require for the manufacturers/suppliers.
Is the business included as an Additional Insured-Vendor under each manufacturer's/supplier's Product Liability insurance?
Foreign-Manufactured Product Information
Please provide a description of the business's products that are imported, manufactured, or assembled by or from a foreign company.
Please provide the following information for the products described above.
Does the business have a written contract with the manufacturer/assembler of their products?
Does the contract require prior approval of any changes in design, components, component
suppliers and/ or manufacturing processes?
Is the business's Quality Assurance Program administered by an independent Quality Assurance provider?
What is the name of the Quality Assurance provider?
What is the address of the Quality Assurance provider?
Is the business's Internal Quality Assurance Program administered in-house by staff dedicated full-time to Quality Assurance?
Is the business's Quality Assurance Program accredited by, certified by, or registered with any governmental or industry body or agency?
What is the name of the accrediting body or agency?
Please provide the following information regarding the types of accreditation, certification or registration.
Please select the components included in your Quality Assurance Program. (Select all that apply)
Foreign-Manufactured Product Information - End
Domestic Contractor Information
Does the business contract the manufacturing or assembly of its product(s) to a domestic company?
Does the business have a formal written agreement with each sub-manufacturer?
Please upload the section(s) of the agreement(s) pertaining to Product Liability and Product Liability insurance.
Does the business obtain Certificates of Insurance from all suppliers evidencing Product Liability insurance?
Please describe the minimum limits of insurance required for all suppliers.
Does the business or others on behalf of the business install, service, repair or maintain the business's product(s)?
Please provide full details on the installation, service, repair, and/or maintenance arrangements the business has in place.
Please upload a copy of the business's standard written contract for installation, service, repairs, and/or maintenance work.
What percentage of sales is generated by installation, service, repair and maintenance work?
Quality Control Information
Does the business maintain formal written quality control and testing procedures?
How long are quality control testing records kept?
Does the business maintain records on when and where its product(s) were manufactured?
How long do you maintain these records?
Does the business maintain records on whom its product(s) were sold to and the date of sale?
How long do you maintain these records?
Does the business maintain records on who supplied the parts and/or supplies going into its product(s)?
How long do you maintain these records?
Does the business maintain records on changes in design?
How long do you maintain these records?
Does the business maintain records on changes in advertising material?
How long do you maintain these records?
Please describe who designs the business's product(s).
Are the business's product designs reviewed, tested and verified by others?
Please share who reviews, tests, and or verifies product designs.
Please list the credentials of the entity who reviews, tests, and verifies product designs.
Are all warning labels and instructions for use reviewed by outside counsel?
Are the business's products subject to any government or industry standards?
Are the business's products in full compliance?
Please describe the standards and their documentation requirements.
Has the business attained ISA 9000, QS 9000 or similar Certification?
Does the business offer training or instruction in the use of its product(s)?
Does the business certify trainees?
Does the business have a formal written product recall procedure?
Please upload a copy of the products recall procedure.
Has the business voluntarily or involuntarily recalled, or is it considering recalling, any known or suspected defective products from the market?
Please provide a description of the recall activity.
Does the business or others (including suppliers and contract manufacturers) manufacture, create or use carbon nanotubes or fullerenes in any product manufactured, sold or distributed?
Please describe the end products or component parts in detail.
Are nanoscale materials or nanoparticles other than carbon nanotubes and fullerenes used by the business or others (including suppliers and contract manufacturers) in the manufacture or creation of any product, or any product, sold or distributed?
Please describe the nanoscale materials, nanoparticles and end products in detail.
Are you aware of any incident, condition, circumstance, defect or suspected defect in any product of work, which may result in a claim or claims against the business that are not listed previously in this form?
Please provide a description.
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 the business's product(s)?
Please provide a description.
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 the business's product(s)?
Please provide a description.
Claims Information
Has the business had any insured or uninsured losses in the last five years? *
Please select the number of previous policy periods during which the business had claims. *
First Policy Period Claims
Please enter the policy period.
What was the name of the insurance carrier during this period?
What was the deductible/self-insured retention during this period?
What is the claims valuation date?
MM slash DD slash YYYY
How many claims were there during this policy period?
How much money did the insurance company reserve to pay the claim(s)?
How much money did the insurance company pay for the claim(s) during this policy period?
What was the total incurred amount for claims during this policy period?
Second Policy Period Claims
Please enter the policy period.
What was the name of the insurance carrier during this period?
What was the deductible/self-insured retention during this period?
What is the claims valuation date?
MM slash DD slash YYYY
How many claims were there during this policy period?
How much money did the insurance company reserve to pay the claim(s)?
How much money did the insurance company pay for the claim(s) during this policy period?
What was the total incurred amount for claims during this policy period?
Third Policy Period Claims
Please enter the policy period.
What was the name of the insurance carrier during this period?
What was the deductible/self-insured retention during this period?
What is the claims valuation date?
MM slash DD slash YYYY
How many claims were there during this policy period?
How much money did the insurance company reserve to pay the claim(s)?
How much money did the insurance company pay for the claim(s) during this policy period?
What was the total incurred amount for claims during this policy period?
Fourth Policy Period Claims
Please enter the policy period.
What was the name of the insurance carrier during this period?
What was the deductible/self-insured retention during this period?
What is the claims valuation date?
MM slash DD slash YYYY
How many claims were there during this policy period?
How much money did the insurance company reserve to pay the claim(s)?
How much money did the insurance company pay for the claim(s) during this policy period?
What was the total incurred amount for claims during this policy period?
Fifth Policy Period Claims
Please enter the policy period.
What was the name of the insurance carrier during this period?
What was the deductible/self-insured retention during this period?
What is the claims valuation date?
MM slash DD slash YYYY
How many claims were there during this policy period?
How much money did the insurance company reserve to pay the claim(s)?
How much money did the insurance company pay for the claim(s) during this policy period?
What was the total incurred amount for claims during this policy period?
Documents and Comments
Please use this field to upload any relevant insurance documents.
Please enter any additional remarks in the space below.
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Disclaimer: This online questionnaire is a tool used to gather information. It is not an application for insurance. No insurance coverage will be bound or put into effect by submitting this form.
Consumer disclosure: By checking the box below you authorize the Agency who supplied this form to you to contact you via phone, email, and text messaging; to save and share with business partners the information you provided; to obtain consumer reports that may include credit-based reports (where legally allowed), public records, claims history, and driving records so that they can give you accurate insurance quotes.
