Commercial General Liability Form First Name Last Name Email Address Contact Number Company Name Business Address City State Zip / Postal Code Years in business? Broker: New Policy: New Policy: Yes No Renewal? Renewal? Yes No Policy Number Effective Date Website Current carrier: Limit of Insurance: Deductible: Premium: Expiration: Has any similar coverage been canceled or nonrenewed in the past five years? Has any similar coverage been canceled or nonrenewed in the past five years? Yes No Describe your business operations: Name and address of parent company and all subsidiaries to be insured: (NOTE: Coverage applies ONLY to those entities specifically named in a policy we may issue to you.) Identify entities a parent or subsidiaries. (Please provide Name, address, and Years of business?) Have you merged with or acquired any companies in last 3 years? Have you merged with or acquired any companies in last 3 years? Yes No Provide details and advise how past liabilities were handled in the acquisition. Do you have a formal quality control program? Do you have a formal quality control program? Yes No If Yes, provide details: If No, how do you assure the quality of your products? If any division, product , or product group is to be specifically excluded from coverage, please indicate: What products are manufactured, sold, handled or distributed? Please include Type of Product and Brand, Total Sales of that Product Last Year, Percentage of Sales Outside U.S., and Estimated Sales for Next Year: In what geographic areas/states are these products sold or used? Indicate percentage of sales in each area:(E.g. State: Colorado; Percent of Sales: 88%; Foreign Countries: Turkey; Percent of Sales: 18%) If any products become component parts of another company's products, supply details and include end use applications. If sold to be repackaged under another name, to whom is it sold and what is the eventual name? Are any new products to be introduced/manufactured during the next year? Are any new products to be introduced/manufactured during the next year? Yes No Describe type and expected sales: Do you manufacture any products that are used in the following industries? Do you manufacture any products that are used in the following industries? Pharmaceutical Aviation Motor vehicles Chemical Medical/Health Care Biotechnology Children's furniture Children's toys Sporting Goods Industrial piping/pressurized piping Meat processing/slaughter houses Seafood processing Food manufacturing/processing Offshore If Yes, please advise detail: Top Five Customers: How can your products be identified from those of your competitors? Do you agree to hold all distributors, dealers and suppliers harmless against claims or suits for bodily injury and property damage in connection with your products? Do you agree to hold all distributors, dealers and suppliers harmless against claims or suits for bodily injury and property damage in connection with your products? Yes No Are any products sold or components used by you manufactured by foreign manufacturers? Are any products sold or components used by you manufactured by foreign manufacturers? Yes No Advise details with percent of cost of goods sold that have foreign components. Has any product ever been recalled? Has any product ever been recalled? Yes No If Yes, supply the following details: (1.Date of recall; 2.Product involved; 3. Reason for recall and how discovered; 4.What was the remedy for the problem?; 5. Were the federal/state authorities notified? If yes, on what date? Do you have a formalized recall program? Do you have a formalized recall program? Yes No If Yes, please share a link to a copy of the program: If No, do you have an informal plan? If No, do you have an informal plan? Yes No If Yes, share a link to its outline: Are batch or product records, serial numbers or copies of guarantees/warranty cards maintained that would facilitate tracing whereabouts of products? Are batch or product records, serial numbers or copies of guarantees/warranty cards maintained that would facilitate tracing whereabouts of products? Yes No If Yes, supply details including how long such records are maintained? Are products identified to ensure traceability to date and place of manufacturing? Are products identified to ensure traceability to date and place of manufacturing? Yes No Are critical components identified and traceable to original source? Are critical components identified and traceable to original source? Yes No Are raw materials traceable back to original source? Are raw materials traceable back to original source? Yes No Do you provide vendor agreements to customers of your products and name them as additional insureds? Do you provide vendor agreements to customers of your products and name them as additional insureds? Yes No If Yes, please explain and attach specimen agreements: Does any manufacturer provide vendors protection to you for any product that you distribute? Does any manufacturer provide vendors protection to you for any product that you distribute? Yes No If Yes, please advise which products and explain. Are there any present situations which might give rise to an incident causing a product recall? Are there any present situations which might give rise to an incident causing a product recall? Yes No If Yes, supply details: Have you had any Product Liability claims or Manufacturing/Specification Errors & Omissions Claims that were or were not covered by insurance? Have you had any Product Liability claims or Manufacturing/Specification Errors & Omissions Claims that were or were not covered by insurance? Yes No If Yes, advise details: Have you been cited by any regulatory agency for violations arising out of business activity involving your product? Have you been cited by any regulatory agency for violations arising out of business activity involving your product? Yes No If Yes, provide details: What percentage of your manufactured product sales are based on customer specification? What percentage of your manufactured product sales are based on your design? Are you ISO 9000 certified? Are you ISO 9000 certified? Yes No Year of recognition: Do you service or repair your products or others' products at your premises or another location? Do you service or repair your products or others' products at your premises or another location? Yes No If Yes, provide details: Do you have any discontinued products? Do you have any discontinued products? Yes No If Yes, please explain the reasons for discontinuing: Any 3-D printing used to manufacture insured's products either by the insured or by a third party on behalf of the insured? Any 3-D printing used to manufacture insured's products either by the insured or by a third party on behalf of the insured? Yes No During the past five years, has any insurer ever canceled or non-renewed similar insurance to any applicant or has your insurance been canceled for non-payment of premium by any insurance or finance company? During the past five years, has any insurer ever canceled or non-renewed similar insurance to any applicant or has your insurance been canceled for non-payment of premium by any insurance or finance company? Yes No If Yes, please explain: Is your company aware of any occurrences, facts, circumstances, incidents, situations, damages or accidents (including but not limited to :allegations of faulty or defective products, product failure, product dispute bodily injury or property damage) arising out of or related to your products that a reasonably prudent might expect to give rise to a claim or lawsuit whether valid or not which might directly or indirectly involve the company? Is your company aware of any occurrences, facts, circumstances, incidents, situations, damages or accidents (including but not limited to :allegations of faulty or defective products, product failure, product dispute bodily injury or property damage) arising out of or related to your products that a reasonably prudent might expect to give rise to a claim or lawsuit whether valid or not which might directly or indirectly involve the company? Yes No Applicant name: Title: FEIN#: Submit
