Product liability insurance application

Section 1: Company details

Company Name

Mailing Address

Street Address

City

State

Zip

Is your Physical Address the same as your Mailling Address?

Yes

Physical Address

Street Address

City

State

Zip

Telephone

Fax

Website

Contact Name

Phone

Other Legal Status

List the names of all predecessor organizations of the Applicant

Federal Tax ID Number

Number of years in business

Is the Applicant controlled by, owned by, or commonly owned, affiliated, or associated with any other organization?

Yes

If yes, provide details

Does the applicant have a policy with Veracity currently?

Yes

Total years of experience in this type of business

Please state the number of full-time employees

Please state the number of part-time employees

Section 2: Specified products and completed operations

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.

Total gross receipts from all products and services listed above:

Estimated annual gross receipts for the coming year ($)

Annual gross receipts in the last 12 months ($)

Annual gross receipts in first prior year ($)

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

Yes

If yes, provide details

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

Yes

If yes, provide details

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

Yes

If yes, provide details

Do any of your products contain CBD?

Yes

Do any of your products have ingestible CBD exposure?

Yes

What Percentage of Sales:

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

Yes

Section 3: Processing and Quality Control

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

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

If yes, explain

Does the Applicant have a quality control and testing procedure?

Yes

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

Can the Applicant identify its product(s) from those of competitors?

Yes

Do all records show the date of purchase and to whom each product was sold?

Yes

Does the Applicant require certificates of insurance evidencing Products Liability Insurance from suppliers?

Yes

Who designs the Applicant's products?

Are product designs reviewed, tested, and verified by others?

Yes

Does the Applicant have a specific program to withdraw known or suspected defective products from the market?

Yes

Has the Applicant ever recalled or is it considering recalling any product?

Yes

Have the Applicant’s products, ingredients, or components thereof ever been the subject of any investigation, enforcement action, or notice of violation of any kind by any government, quasi-government, administrative, regulatory, or oversight body?

Yes

If yes, provide details

Section 4: Manufacturing and distribution

Are all the products sold considered "Generally Regarded Safe" by the FDA?

Yes

Do you import any products from other countries?

Yes

If yes, please list countries

Do you export products or have foreign operations?

Yes

If yes, please list countries

Do you make or sell any of the following products?

Do you make or handle any products that are explosive, flammable, or poisonous either by itself or in combination with other materials?

Yes

Could any of your products be classified as pharmaceuticals?

Yes

If yes, provide details

Do others private-label your products?

Yes

If yes, provide details

Limits of Liability requested:

The company does not guarantee to offer any of the above limits and/or deductibles.

Per Occurrence ($)

Annual Aggregate Limit ($)

Deductible ($)

Do you currently have liability insurance?

Yes

Insurance Company

Limits of Liability

Deductible/SIR

Expiring Premium

Expiration Date

Retroactive Date

Please request loss runs/claims history from your current insurance company

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

If yes, provide details

Section 5: Claims history

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

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

If yes, provide details

Section 6: Property coverage

Do you need property coverage?

Yes

Underwriting information:

Construction Type:

Frame/Brick Veneer

Masonry

Metal

Yr. Built

# Stories

Square Footage

Is building over 25 years old?

Yes

Year of updates for heating

Year of updates for electrical

Year of updates for roof

Year of updates for plumbing

Miles from the Fire Station

Feet from Fire Hydrant

Is the building Sprinklered (Fire Suppression System)?

Yes

If yes, what percentage

Do you have an alarm?

Yes

If yes, what type?

Local Gong

Central Station

Fire and/or Burglar

Is property located within 5 Miles of any coast?

Yes

Coverage information:

Requested Effective Date

Coverage Information

Building – If Owned:

Limit of Insurance

Deductible

Policy Form

Co-Insurance

Valuation

Business Personal Property:

Limit of Insurance

Deductible

Policy Form

Co-Insurance

Valuation

Business Income:

Limit of Insurance

Deductible

Policy Form

Co-Insurance

Valuation

Lien Holders/Mortgage Holders:

Prior carrier/claims:

Current Insurance Carrier:

Number of Yrs. Insured:

Expiring Premium:

Have you had any claims in the past 5 years?

None

Yes

If you answered "Yes" please provide the following information

Section 7: Additional information

Please attach the following: brochures, labels, and instructions.

File

Section 8: Warranties

Notice to the Applicant - Please read carefully

No fact, circumstance, or situation indicating the probability of a claim or action for which coverage may be afforded by the proposed insurance is now known by any person(s) or organization(s) proposed for this insurance other than that which is disclosed in this application. It is agreed by all concerned that if there is knowledge of any such fact, circumstance or situation, any claim subsequently emanating therefrom shall be excluded from coverage under the proposed insurance. For the purpose of this application, the undersigned authorized agent of the person(s) and organization(s) proposed for this insurance declares that to the best of his/her knowledge and belief, after reasonable inquiry, the statements in this application and in any attachments, are true and complete. The Company is authorized to make any inquiry in connection with this application. Signing this application does not bind the Company to provide or the Applicant to purchase the insurance.

If the information in this application and any attachment materially changes between the date this application is signed and the effective date of the policy, the Applicant will promptly notify Veracity Insurance Solutions, LLC, who may modify or withdraw any outstanding quotation or agreement to bind coverage.

The undersigned declares that the person(s) and organization(s) proposed for this insurance understand that:
(i) The policy for which this application is made applies only to “Claims” first made during the “Policy Period.”
(ii) Unless amended by endorsement, the limits of liability contained in the policy shall be reduced, and may be completely exhausted by “Claim Expenses” and, in such event, the Company will not be liable for “Claim Expenses” or the amount of any judgment or settlement to the extent that such costs exceed the limits of liability in the policy.

Warranty:

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.

Date

Signature

Please sign your name in this area using your mouse (Desktop) or finger (Tablet, Phone).

Print name

Title

How did you hear about us?

If you are currently working with a Veracity Broker please enter their name:

Broker name