/ P. O. Box 5866
Columbia, SC 29250-5866,
Phone: (800) 622-7370
Fax: (803) 256-4017
Email:

A. APPLICANTProposedEffectiveDate:

1.FullName(andlistallsubsidiarycompanies):

2.Areyouabroker?

Ifyes,AgencyName/Contact: AgencyPhone: AgencyContactEmail:

3.MailingAddress:

4.Location(s):

5.Applicantis:IndividualPartnershipCorporationJointVentureOther:

6.Applicant’sOperations:

Manufacturer

DistributorImporterExporter

Manufacturer’s RepOther:

7.Yearsinbusiness:8. Website:

B. PRODUCTSANDCOMPLETEDOPERATIONS

8.Listcompletedescriptionof productsmanufactured,soldordistributedbytheapplicant(attachproducts brochure,printedwebsiteinformation,labelsorotherprinteddescriptivematerials)

Ofwhatmaterialsorprincipalcomponentsarethesecomposedof?

9.Doyoumanufacture*thecompleteproduct?Ifnot,whatcomponentpartsare purchasedbyyou? Whoarecomponentpartspurchasedfrom?

*Ifproductsnotmanufacturedbyapplicant,areactualmanufacturersintheUS?

Andif so,dotheycarrydomesticproductsinsuranceatlimitsof$1MMorgreater? DoyourequireCertificatesof Insurance?

Areanyforeignproducts/componentsinvolved?

YesNo

YesNo

YesNo

10.WillVendorsCoveragebewanted?

11.Willanyvendorrepackage,re-labelormodifyyourproduct?

YesNo

YesNo

Ifyes,explain:

12.Listallproductsmanufacturedbytheapplicantbutnotsoldunderits label:

13.Numberof unitssoldannually:Costperunit:

14.TOTALSALES(next12months)$PriorYears1st$

2nd$

3rd$

4th$

5th$

15.ListyourtopFive(5)Customers:

1)

2)

3)

4)

5)

16.Anyforeignsales?YesNoIfso,howmuch?

17.Doestheapplicantinstall/apply/erecttheproduct?

Doyousupervisetheassemblyof theproduct?

YesNo

YesNo

Whereistheproductassembled?

18.Anyproductsassembledbytheenduser?

YesNo

19.Listanyproductthat hasbeendiscountedorrecalledinthepast5yearsandwhy:

13. / Isthereawrittenproductsrecallplan? / Yes / No
14. / Anynewproductsintroducedinthepast5years? / Yes / No

Ifyes,listproduct(s)andwhenintroduced:

15.Areanynewproductsproposedfor introductioninthenext12months?YesNo

Ifyes,listproduct(s):

16.Canproductsbeidentifiedfrom thoseof competitors?YesNo

17.Areanyproductssoldascomponentsforotherproducts?

YesNo

Ifyes,indicateuses:

18.Couldanyof yourproductsorservicesbeusedonorinconnectionwith:

pharmaceuticals/cosmetics/vitamins/herbs? aircraft/missile/aerospace?

watercraft or offshore?

transportation/pollution/waste treatment?

YesNo

YesNo

YesNo

YesNo

19.Anyholdharmlessagreements,warranties,guaranteesgivento anysupplier, distributor, orpurchaser?

(Ifyes,attachcopies)

C.QUALITYCONTROL/LOSSCONTROL

  1. Areyourproductstestedandlabeledtomeetgovernmentand/orindustrystandards

YesNo

YesNo

Ifyes,liststandards:

AnyproductsULapproved? AnyproductsFDAapproved?

AnyproductsnotapprovedbyUL,FDA, and/oranyoneelse?

YesNo

YesNo

YesNo

Ifyes,bywho?

  1. Listyourmembershipsinanyindustryproduct–standardorganizations(ex. ISO9000)

  1. Isawrittenlosscontrolprogramineffect?

Anywrittenqualitycontrolprocedure?

YesNo

YesNo

D.WARNINGS

  1. Arehazardsinherentinthefinalproduct,andwarningsagainstforeseeablemisuseandabuse, made known totheultimate user by:

Warninglabelsatthepointofhazards? Writteninstructions?

Othermeans?(Ifyes,attachdetails)

E.CLAIMSHISTORY

  1. Anyclaimsinthepast5years?

(Ifyes, attachcurrently-valued(withinpast90days)lossrunsincludingdetails)

  1. Areyouawareofanyincident(s)thatmayresultinaclaimnotreflectedinquestionE.1?

YesNo

YesNo

YesNo

YesNo

YesNo

F.EXPIRINGCARRIERINFORMATION

Carrier: Premium: $ Term:

Limits: $ Rate: $ Deductible/SIR: $

CoverageForm:

OccurrenceClaimsMadeRetro Date:

Requested coverage/limits for the new term:

Hasanycarriercancelledorrefusedto renewproductsliability?

YesNo

Ifyes,explain:

Howdidyouhearaboutus?

WARRANTY:ThepurposeofthisSupplementalApplicationistoassisttheunderwritingprocess.Information containedhereinisspecificallyrelieduponindeterminationofinsurability.Theundersignedthereforewarrants thattheinformationcontainedherein(consistingoffourpages)istrueandaccuratetothebestofhis/herknowledge, informationand belief.The SupplementalApplication, and the applicationtowhich it is appended, shallbe the basis ofany insurancepolicy thatmay beissued andwill bepart ofsuch policy.

Signature ofApplicantTitleDate

INCLUDETHEFOLLOWINGITEMS:

Pictures,brochure,nutritionalfacts,labels,recallprocedures.