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 / No14. / 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
- Areyourproductstestedandlabeledtomeetgovernmentand/orindustrystandards
YesNo
YesNo
Ifyes,liststandards:
AnyproductsULapproved? AnyproductsFDAapproved?
AnyproductsnotapprovedbyUL,FDA, and/oranyoneelse?
YesNo
YesNo
YesNo
Ifyes,bywho?
- Listyourmembershipsinanyindustryproduct–standardorganizations(ex. ISO9000)
- Isawrittenlosscontrolprogramineffect?
Anywrittenqualitycontrolprocedure?
YesNo
YesNo
D.WARNINGS
- Arehazardsinherentinthefinalproduct,andwarningsagainstforeseeablemisuseandabuse, made known totheultimate user by:
Warninglabelsatthepointofhazards? Writteninstructions?
Othermeans?(Ifyes,attachdetails)
E.CLAIMSHISTORY
- Anyclaimsinthepast5years?
(Ifyes, attachcurrently-valued(withinpast90days)lossrunsincludingdetails)
- 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.