PRODUCT LIABILITY SUPPLEMENT This is a supplement to the ISO acord applications. Failure to provide answers to all questions will delay your quotation. Applicants Instructions: 1. Answer all questions. If the answer is NONE, please state NONE. Do not use N/A or Not Applicable 2. Please read carefully the Application Warranty statement at the end of this application. 3. Please attach the following information: a) Product brochures, catalogs, service agreements, labels, and/or instructions. b) Current financial statements (or pro forma) 1. Applicant Please type or print Proposed Effective Date: A. Full name of applicant: B. Principal address: C. Website address: D. Contact: E. Email Address: F. Corporation Partnership Proprietorship Other G. Years in business under present name: H. Have you or any principal ever engaged in this or similar enterprises under a different name? No Yes If so, provide/attach full details: I. Describe present or past affiliations with other firms: J. Estimate for upcoming year: Domestic Sales/Receipts/Revenues: $ Foreign Sales/Receipts/Revenues: $ Payroll Estimate: $ K. Indicate percentage of activity conducted: Manufacturer Wholesaler Retailer Contractor Importer Exporter Distributor Other www.usxs.net Brokers@usxs.net 1 of 7
2. Specifications Requested Present A. Limits of Liability: B. Self Insured or Deductible: C. Retroactive date: (if applicable) D. Present Insurer: Premium: $ E. Has any insurance company cancelled, restricted, or refused to renew your products liability insurance? Yes No 3. Products and Completed Operations A. Describe your products and services: B. Indicate which product you distribute, install, service or repair: C. Products acquired via acquisition or merger: D. Did you assume liability for these products? No Yes-If yes, explain: E. Do you retain liability for products or divisions that you no longer control? No Yes-If yes, explain: F. Have you ceased to manufacture any product during the past five years? No Yes-If so, attach full details, including description of product, why discontinued, sales, and losses by year: www.usxs.net Brokers@usxs.net 2 of 7
G. Do you plan to introduce any new products or services? No Yes-If so, attach full details: Five Year Sales History (Plus Estimate for Next 12 Months). For Discontinued Products coverage provide sales and number of units for the past five years and estimated time product will remain in the marketplace. Sales Name of Principle Product of total sales # of Units Estimated (Next 12 months) $ Past 12 months $ 1 st Previous Year $ 2 nd Previous Year $ 3 rd Previous Year $ 4 th Previous Year $ PLEASE PROVIDE DETAILS TO ANY POSITIVE RESPONSES ON SEPARATE SHEET PROVIDED. Replacement Parts are what percentage of Sales? I. Has there been a significant change in product mix? Yes No J. Do you import products or component parts? Yes No K. Do you export products or have foreign operations? Yes No L. Could any of your products or services be used on or in connection with: Aircraft / Aerospace/Missile? Yes No Cosmetics / Herbs / Pharmaceuticals / Vitamins Yes No Watercraft / Offshore Rigging or Drilling? Yes No Pollution/Waste Treatment / Transportation? Yes No M. Do you manufacture or handle any product that is explosive, flammable, or poisonous either by itself or in combination with other materials Yes No N. Do you change, alter, re-label, or place your company s name on any product distributed by you? Yes No O. Are any of your products sold under another company s name or label? Yes No P. Do you purchase materials or components for others? Yes No Q. Do you assemble your products? Yes No R. Do you install your product? Yes No S. If your product is assembled by others, do you supervise? Yes No T. If your product is installed by others, do you furnish instructions for installation? Yes No If yes, attach a copy of instructions. U. What percentage of your product is distributed to: www.usxs.net Brokers@usxs.net 3 of 7
Wholesalers Retailers Consumers West Midwest East V. Suppliers and Distributors: Do you hold them harmless or insure them? (Please provide copy of indemnification agreement) Yes No Do they hold you harmless or insure you? (Please provide copy of indemnification agreement) Yes No If yes to either of above please explain: 4. Claim History A. Total aggregated losses, from first dollar, including expenses: PRIOR CARRIER AND LOSS HISTORY (PAST 5 YRS) Secured from Prior Carrier Insured Policy Period Carrier Premium Rate Deductible Limit # of Claims Amount Paid Amount Current $ 1st Prior $ 2nd Prior $ 3rd Prior $ 4th Prior $ Reserved B. Individual losses valued at $10,000 or more, from first dollar including expenses: Date of Claim Product Involved Describe Occurrence and Injury or Damage Amount Paid Amount Reserved C. Are you aware of any other incidents, conditions, circumstances, defects, or suspected defects, which may result in claims against you? Yes No If yes, give details: www.usxs.net Brokers@usxs.net 4 of 7
5. Loss Prevention Product Design Quality Control A. Has your product ever been subjected to any inquiry by any Government Agency concerning the efficacy, adequacy of labeling, hazardous contents, or safety? If yes, attach full details and results of such inquiry. No Yes B. Do you have a written products recall plan? If yes, please attach copy. No Yes C. Have you ever recalled products because of a potential product safety hazard? No Yes If yes, please attach details and indicate of recovery. D. Do you do your own design work? No Yes E. Do you maintain records of design changes and justification for these changes? No Yes F. Are your designs subject to independent external review, testing, or certification? No Yes G. Are your products designed, tested, labeled, and manufactured to meet or exceed all government and industry standards? No Yes H. Are written testing procedures followed? No Yes I. How long are quality control and testing records kept? J. Supplies and components: 1. Are they ordered to your specifications? No Yes 2. Have you determined which ones are critical to the safety of your final product? No Yes 3. List those critical items, indicate whether testing is on a sample basis or on all units: 4. Are warranties obtained from all suppliers? No Yes 6. Instructions Warnings Loss Control Defense A. Do you provide any specific training/instruction for the ultimate user in the proper use of your product? No Yes If yes, please describe: B. Explain how you identify your products and parts from similar competitors products and parts: C. Can you determine based on available records for all products you have sold: 1. When any given product item was manufactured? No Yes www.usxs.net Brokers@usxs.net 5 of 7
2. To whom it was sold, and the date of sale? No Yes 3. Who supplied the parts and supplies? No Yes D. Accident Procedures: 1. Do you have a written procedure for obtaining information about product complaints, accidents, and/or injuries? No Yes 2. Does your procedure provide for examining and preserving any allegedly defective product, with the results of such examination recorded? No Yes 7. Furnish a description of the products or services you wish to have insured: Application Warranty This application shall not be binding unless and until a policy shall be issued and then only as of the effective date of said policy and in accordance with all terms thereof. The Applicant hereby warrants and agrees that the foregoing statements and answers are just, full and true representations of all the facts and circumstances with regard to the risk to be insured, insofar as same are known to the Applicant, and the same are hereby made the basis and a condition of the insurance, and a warranty on the part of the insured. If any information provided by the applicant in this application is found to be false or misleading and would alter the company s decision to provide the insurance coverage applied for, it is agreed between the company and the applicant that the coverage, if under binder or policy, is subject to immediate cancellation. It is mutually understood and agreed between the Company and Applicant that any inspection of premises, operations, or any matter pertaining to insurance afforded by the Company, is made for the use and benefit of the Company only, and is not to be relied upon by the Applicant in any respect. Signature of Producer Date Signature of Applicant Date Principal Officer 6929 W. 130 th St., Suite 100 Cleveland, OH 44130 440-888-7300 Fax: 440-888-7380 www.usxs.net Brokers@usxs.net 6 of 7
Additional Explanations to the Questions Designated Question No. Explanations www.usxs.net Brokers@usxs.net 7 of 7