Section 1: Company Details
Section 2: Product and sales data
Sales Exposure Information (in $):
Next 12 months (Projected)
Last 12 months (Expiring)
Section 3: Insurance Information
Please indicate the limits of liability desired: (i.e., $1,000,000 each occurrence, $2,000,000 aggregate, and $2,000,000 product liability)
Please request loss runs/claims history from your current insurance company.
Section 4: Manufacturing and Distribution
Section 5: Marketing
Percentage of Total Sales to:
Section 6: Loss Prevention
Section 7: Property Coverage
Business Personal Property
Section 8: Product Design and Quality Control
Section 9: Instruction / Warnings / Advertising / Warranties
Section 10: Loss Control and Defense
Can you determine, based on available records, for all products you have sold:
Section 11: Accident Procedure
Section 12: Additional Information
I/We warrant to the Company, that I/We understand and accept the notice stated above and that the information contained herein is true and that it shall be the basis of the policy and deemed incorporated therein, should the Company evidence its acceptance of this application by issuance of a policy.
Note: This application is signed by undersigned authorized agent of the Applicant(s) on behalf of the Applicant(s) and its owners, partners, directors, officers, and employees.
If you are currently working with a Veracity Broker please enter their name: