GENERAL LIABILITY APPLICATION

Applicant's Name:
Mailing Address:
City    State        Zip
Phone:      Fax:

PROPOSED EFFECTIVE DATE:
From     To
12:01 A.M. Standard Time at the address of the Applicant
Email Address:
LIMITS OF LIABILITY REQUESTED
  General Aggregate $  
  Products & Completed Operations Aggregate $  
  Personal & Advertising Injury $  
  Each Occurrence $  
  Fire Damage (any one fire) $  
  Medical Expense (any one person) $ Excluded  
  Other Coverages, Restrictions and/or Endorsements
Deductible  
 
$

ANSWER ALL QUESTIONS - IF THEY DO NOT APPLY, INDICATE 'NOT APPLICABLE'

APPLICANT/PREMISES/OPERATIONS INFORMATION
1. Describe all business operations conducted by applicant:
2. Premises information (attach schedule if necessary):
Loc. No.
Street Address
City
County
State
Zip Code
Interest
Part Occupied
 
 
 
 
 
 
 
 
 

3. Applicant is:   Individual Corporation Partnership Joint Venture
                            Other (Specify)

 4. Inspection/Audit
     Inspection (contact and phone):
     Accounting Records (contact and phone):

 5. Management:
     Number of years in operation:    If new operation, number of years related experience:

 
GENERAL INFORMATION (Explain all "yes" responses)
 
Yes
No
 
Yes
No
1. Exposure to flammables, explosives, chemicals?
2. Exposure to asbestos?
3. Exposure to radioactive materials?
4. Do operations involve storing, treating,
    discharging, applying, disposing or
    transporting of hazardous material (e.g.,
    landfills, wastes, fuel tanks, etc.)?
5. Sporting/social events sponsored?
6. Any watercraft, docks, floats owned, hired, or
    leased?
7. Any operations sold, acquired, or discontinued
    in last five years?
8. Is applicant a subsidiary of another entity or
    does applicant have any subsidiaries?








 
9. Machinery/equipment loaned/rented to others?
10. Swimming pool on premises?
11. Any parking facilities owned/rented?
12. Fee charged for parking?
13. Does insured subcontract work?
14. Certificates of Insurance required from all
      subcontractors?
15. Any demolition exposure contemplated?
16. Any structural alterations contemplated?
17. Recreational facilities provided?
18. Any policy or coverage declined, cancelled or
      nonrenewed during last three years?
 


PRIOR CARRIER INFORMATION

Year:
Year:
Year:
Year:
Year:
Carrier
  
  
  
  
  

Policy Number

  

  

  

  

  

Total Premium

$

$

$

$

$
LOSS HISTORY - FIVE YEAR PERIOD
Date of Loss
Description of Loss
Amount Paid
Amount Reserved
Claim Status
(Open or Closed)
$
$
$
$
$
$
$
$
$
$

SCHEDULE OF HAZARDS
Loc. No.
Classification
Class.
Code
Premium Bases:
(a) Gross Sales
(p) Payroll (a) Area
(c) Total Cost (t) Other
Terr

 TRANSITION
 1. Has the risk or any location not qualified for transition? Yes    No
 2. If this risk qualifies for transition, indicate year it first qualified:


 Name and Phone Number of Individual to contact for Inspection/Audit:

Product Liability Supplemental Questionnaire

Preparation Instructions:
•  Answer all questions. If the answer to any question is None, please state “None”
•  Application must be completed by Owner, Partner or Officer.
•  Brochures, copies of guarantees, warranties and hold harmless agreements furnished by the named insureds should accompany the application.    You may email them to sales@yancyinsurance.com
•  The latest 10K and 10Q, or if a privately held business, latest audited financial statement and latest quarter income report should be furnished.

1. APPLICANT INFORMATION
A) Name (First Named Insured and other Named Insureds):
     

B) List all Applicants' web sites:
    

2. DESCRIPTION OF OPERATIONS
    

3. SPECIFIED PRODUCTS AND COMPLETED OPERATIONS

A) Only those products and services specified below will be considered for coverage. Refer to key below

Products

(Specific Category)
Applicant Acts as a / an
No. of Years
% Gross Sales
Does Applicant
Products Sold To

M

W

R

I

MR
Install
Repair Service
W
R
MC
C
O
   M = Manufacturer         R = Retailer         MR = Manufacturer's Rep         W = Wholesaler              I = Importer        C = Consumer-Direct
   Other (Specify)

B) Have you discontinued or are you considering discontinuing any product to be covered by this insurance? Yes        No
     If Yes, please describe:

C) Are any new products planned for sale during the next 12 months? Yes        No

D) Do you import component parts? Yes        No

E) Do you export products or have foreign operations? Yes        No

F) Do you know that any of your products or services is used in connection with aircraft/missiles/aerospace? Yes        No

G) Are any of your products or services subject to registration/regulation/review by any governmental agency? Yes        No
     If so, which agency?

PLEASE EXPLAIN ANY “YES” ANSWERS:

4) SALES HISTORY

A) Total sales or receipts for all products and services:
     Past 12 Months $    1st Prior Year $    2nd Prior Year $
     Describe any significant change in product sales mix between any prior year and next year's projection:
     

B) Do you wish to provide your customers with vendors coverage? Yes        No
     If Yes, name of vendor and your annual sales through that vendor:
     Your product:

5) OPERATIONS, ADDITIONAL LIABILITIES & UNIQUE CHARACTERISTICS

A) Do others manufacture, assemble, package or install products under your name or label? Yes        No
     If Yes, please explain:

B) Do you manufacture, assemble, package or install products for others under their name or label? Yes        No
     If Yes, please explain:
     

C) Have you sold any business in which you retained liabilities? Yes        No
     If so, please furnish details including lists of products manufactured, assembled, packaged or installed by you prior to the date sold:
     

D) Can you identify your product from those of competitors? Yes        No
     How?
     If No, please explain:
     

6) CLAIMS HISTORY – FIVE YEARS OR MORE (LOSS RUNS MUST BE FURNISHED)

A) Total Aggregates Losses, Including Defense Costs:
Policy Period
No. of Claims
Total Amounts Paid
Amounts in Reserve
Valuation Date
Indemnity
Expense
Indemnity
Expense

B) Describe individual losses, valued $25,000 or more, including defense costs:
    

C) Are you aware of any other occurrences, incidents, conditions, defects or suspected defects, which may result in claims against you?
     Yes     No

    If Yes, give details:
    

7) DESIGN, QUALITY CONTROL, RECORDKEEPING, WARNINGS & CLAIM DEFENSE
 
YES           NO
A) Who designs your products?
B) Do you require certificates evidencing design or Architects and Engineers Errors & Omissions Insurance?
      

C) Are your products designed, tested, labeled and manufactured to meet or exceed all applicable government and industry standards?
      
D) What government/industry standards must your products meet (i.e. OSHA, UL, ANSI, ASME)?
Identify Top 3 Standards (incl. standard numbers) 1)    2)   3)
E) Are designs reviewed, tested and verified by others outside the company?
      
F) Do you have a Quality Control Program?
      
G) If you have a Quality Control Program, is it written?
      
H) Which of the following elements does your Quality Control Program include?
    1) Written specifications/requirements for suppliers of raw materials and/or components?
      
    2) Tests of materials and components received from suppliers to determine conformance?
      
    3) Are products tested at various stages to verify conformance with written standards?
      
    4) Are finished products tested to verify they meet performance requirements?
      
    5) Do you retain your records of test results?
      
    6) How long do you retain your records?
F) Do your records indicate when each product was manufactured?
      
G) Do your records show to whom and the date each product was sold?
      
H) Do your records show who supplied the component parts going into your products?
      
I) Do you require certificates from your suppliers evidencing products liability insurance?
      
J) Are you ISO 9000 (9001, 9002, 9004) and/or QS9000 registered?
      
    If yes, who is the registrar (i.e. TUV)?
K) Do you ever draw plans, designs or specifications for any products for others?
      
    If Yes, do you carry design or Architects and Engineers Error & Omissions Insurance?
      

L) Does legal counsel periodically review all instructions, operating manuals, advertisements and warranties to avoid misunderstandings relative to product safety or intended use?
      
    How often?  
M) Do you maintain records of changes in designs, advertisements and sales brochures?
      
N) Do you have a specific program to withdraw known or suspected defective products from the market?
      

O) Have you ever recalled (either voluntarily or involuntarily) or are you considering recalling any known or suspected defective products from the market?
      
    If Yes, please furnish details:  
P) Do you furnish any guarantees, warranties, or hold harmless agreements?
      
    If Yes, please furnish details:  

Q) List your memberships in any industry product-standard organizations:

1)    2)    3)    4)

 

NOTICE TO KENTUCKY, NEW YORK AND OHIO APPLICANTS: Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information, or conceals for the purpose of misleading, information concerning any fact material thereto, commits a fraudulent act, which is a crime and in New York punishable by a fine of up to $5,000.

Applicant's Name & Title:     Date: