Product Liability Insurance Quote

Insured Name

DBA (If applicable)

Street Address

City

State

Zip

Is your Physical Address the same as your Mailling Address?

Yes

No

Street Address

City

State

Zip

Mobile Phone

Email

Website

Entity Type

Other Legal Status

Federal Tax ID Number

Annual Sales

If yes, provide details

Total years of experience in this type of business

Please state the year your business was started.

Please state the number of owners for this business

Provide the following information for those products and/or services for which the Applicant wants coverage. Only those products and services listed below will be considered for coverage.

What are the total annual gross receipts from all the products and services listed above?

Is the Applicant presently considering any change in the mix of products, including adding new products or services, for the coming year?

Yes

No

If yes, provide details

Has the Applicant discontinued or is it considering discontinuing any product or service listed above?

Yes

No

If yes, provide details

Are any of the Applicant’s products or services used in connection with aircraft/missiles/aerospace?

Yes

No

If yes, provide details

Do any of your products contain CBD?

Yes

No

Do any of your products have ingestible CBD exposure?

Yes

No

Do you source your CBD from legally grown hemp plants as described in the H. R. 2 Agricultural Improvement Act of 2018?

Yes

No

Do any products, ingredients, or components thereof originate outside the United States?

List countries of origin

Name of each organization manufacturer, distributor, or supplier

Do others manufacture, assemble, package, or install products under the Applicant’s name or label?

Yes

No

If yes, provide the name(s) and address(es) of contract manufacturer(s)

Does the Applicant manufacture, assemble, package, or install products for others under their name or label?

Yes

No

If yes, explain

Does the Applicant have a quality control and testing procedure?

Yes

No

If yes, how long does the Applicant keep quality control and testing records?

Per Occurrence ($)

Annual Aggregate Limit ($)

Deductible ($)

Do you currently have liability insurance?

Yes

No

Insurance Company

Limits of Liability

Deductible/SIR

Expiring Premium

Expiration Date

Retroactive Date

Has any insurer declined, cancelled, or nonrenewed any product liability insurance or any similar insurance on behalf of any person(s) or organization(s) proposed for this insurance?

Yes

No

If yes, provide details

Has any claim for Product Liability been made against any person(s) or organization(s) proposed for this insurance during the last 5 years?

Yes

No

If yes, please complete the following for the previous five (5) years, including for any predecessor. Attach a description of any loss greater than $10,000 total incurred.

Is (are) any person(s) or organization(s) proposed for this insurance aware of any fact, incident, circumstance, situation, condition, defect, or suspected defect which may result in a Products Liability claim?

Yes

No

If yes, provide details

Product liability insurance application

Section 1: Company details

Mailing Address

Physical Address

Section 2: Specified products and completed operations

Section 3: Processing and Quality Control

Section 4: Limits of Liability

Section 5: Claims history