PRODUCER
/ PHONE(A/C, No, Ext): /
APPLICANT NAME (First Named Insured) including MAILING ADDRESS AND ZIP CODE:
EFFECTIVE DATE
/EXPIRATION DATE
/ DIRECT BILL /PAYMENT PLAN
/AUDIT
AGENCY BILLFOR COMPANY USE ONLY:
CODE: / SUBCODE: /
SAI NUMBER:
AGENCYCUSTOMER ID:
PLEASE ANSWER ALL QUESTIONS. ADDITIONAL SPACE IS FOUND IN THE REMARKS SECTION BELOW. / YES / NO
Has any Insurance Company ever cancelled, restricted, or refused to renew your Printers Liability/Errors & Omissions coverage in the past 5 years? If so, please explain in the REMARKS section. (Not Applicable in Missouri)
Will Travelers be writing your Products Liability insurance coverage?
Printers Errors and Omissions Liability
LIMITS REQUESTED:
$ 300,000 Each “Wrongful Act”/$ 600,000 Aggregate$ 500,000 Each “Wrongful Act”/$1,000,000 Aggregate
$1,000,000 Each “Wrongful Act”/$ 2,000,000 Aggregate
Other:
DEDUCTIBLE REQUESTED:
$250*$500*$1,000$2,500$5,000$10,000Other______
* Available only for risks written on Master Pac
Product Recall and Correction of Work
LIMITS REQUESTED:
$ 5,000 Each “Wrongful Act”/$ 10,000 Aggregate (default limits)$ 25,000 Each “Wrongful Act”/$ 50,000 Aggregate
$ 50,000 Each “Wrongful Act”/$ 100,000 Aggregate
$ 100,000 Each “Wrongful Act”/$ 250,000 Aggregate
Other:
$1,000(default - minimum required deductible)$2,500$5,000$10,000Other______
OPERATIONS
1.Estimated annual total sales (Printing and Graphic Arts Services only): Current:$______
Projected$______
2. What is the size of: (a) Your average contract? $______
(b) Your largest contract? $______
3.List the approximate percentage of total revenue derived from the following description of type of printing services:
Advertising / promotional inserts, pamphlets, stuffers, and flyers / ______%Artwork Reproduction / ______%
Bindery / ______%
Box printing / ______%
Business forms (envelopes, stationary, business cards) / ______%
Catalog printing / ______%
Corporate / Financial (annual reports, stock reports etc,) / ______%
Coupons or rebate slips / ______%
Currency (money orders, securities, travelers checks etc.) / ______%
Drug or Pharmaceutical Labels / ______%
Food Labels / ______%
Games of chance (lottery, raffle tickets, bingo, pull tabs) / ______%
Graphic Design Services(please describe under remarks) / ______%
Legal documents (contracts, leases, other legal forms) / ______%
Medical Labels / ______%
Newspaper (advertising / want ads) / ______%
Newspaper (general circulation) / ______%
Photocopying or duplicating / ______%
Publishing or content development / ______%
Social printing (invitations, announcements) / ______%
Specialty items (matchbooks, t-shirts, lighters, mugs, menus, maps) / ______%
Technical Documents (blueprints, schematics) / ______%
Telephone Directories / ______%
Tickets - transportation, admission, or special event / ______%
Trademark / logo design / ______%
Warning Labels / Warranty information / ______%
Other (please describe):______
______
______/ ______%
PLEASE ANSWER ALL QUESTIONS. ADDITIONAL SPACE IS FOUND IN THE REMARKS SECTION BELOW. / YES / NO
4.Do you provide any of the services listed above without doing the printing? Please describe:
5. Do you provide mailing and/or distribution services to end recipients (i.e., your customer’s customers) with any of the services listed above? If so please indicate which services and % of sales:
6. Do you run multiple printing jobs at one time? If yes, please describe what methods are used to prevent cross-sequencing?
7. Is any work subcontractedtoothers? If so, please indicate % of total and describe the work subcontracted.
8.Do you perform work as a subcontractor for others? If so, please indicate % of total and describe the work you perform.
9. Do you utilize any new or proprietary technology in your production process? If so, how has the technology been tested for quality control?
10.What would be the worst case scenario for your customer in the event of an error or omission on your part?
QUALITY CONTROL
PLEASE ANSWER ALL QUESTIONS. ADDITIONAL SPACE IS FOUND IN THE REMARKS SECTION BELOW. / YES / NO1. Do you have a written Quality Control program in place?
2.Does your QC program incorporate the Printing Trade Customs” or “Best Business Practices for the Printing Industry” as established by the Printing Industries of America?
3. Are customers required to approve and keep proof copies (especially logo colors) before printing?
4. What methods are used to document approval (sign off) on final proofs?
5. Are job specification sheets maintained for each job?
6. Is the job specification sheet kept up to date throughout the job with changes documented?
7. How long do you maintain documentation for a job?
8. Do you have a formal process for handling customer complaints? If yes, please describe:
9.Do you have a formal process for conducting a recall of your products? If yes, please describe:
CONTRACTS
PLEASE ANSWER ALL QUESTIONS. ADDITIONAL SPACE IS FOUND IN THE REMARKS SECTION BELOW. / YES / NO1. Are written contracts (including electronic “click-through” agreements) always used with customers?
2. Do all customer contracts incorporate and advise of the “Printing Trade Customs” or “Best Business Practices for the Printing Industry,” including disclaimer of warranties and indemnification? If no, please describe how exceptions to standard contracts are handled:
3. Do your contracts address digital asset management issues such as:
- Compatibility of software
- Creation of backup files
- Re-creation of files that have been altered, corrupted or lost?
4.Do your sales and marketing staff receive training on standard and acceptable contract terms?
5.If work is subcontracted to others, do you always use written contracts?
6.Do your agreements with subcontractors always include:
- Indemnification provisions
- Insurance requirements, including additional insured status, E&O coverage, and limits equal to yours?
7.If you perform work as a subcontractor for others, do you assume liability beyond that normally contemplated by Printing Trade Customs?
8.Do you have reciprocal facility use agreements with other printers?
DIGITAL ASSET MANAGEMENT
1. What percentage of your work involves the exchange of electronic files over a network such as the Internet? ______%
PLEASE ANSWER ALL QUESTIONS. ADDITIONAL SPACE IS FOUND IN THE REMARKS SECTION BELOW. / YES / NO2.Do you encrypt files that are being transmitted electronically?
3.Do you have a firewall installed to protect your network? How often do you update it?
4. Do you have anti-virus software on your system? How often do you update it?
5.Do you create, or require that your customers retain, backup copies of electronic files?
REMARKS:
CLAIM/LOSS HISTORY
1.ENTER ALL ERRORS OR OMISSIONS CLAIMS/LOSSES FOR THE PAST 5 YEARS / CHECK HERE IF NONEDATE OF
CLAIM/LOSS / TYPE/DESCRIPTION OF CLAIM/LOSS / DATE OF
CLAIM/LOSS / AMOUNT
PAID / AMOUNT
RESERVED / CLAIM/LOSS
STATUS
OPEN
CLOSED
OPEN
CLOSED
OPEN
CLOSED
2.LIST ANY ERRORS OR OMISSIONS INCIDENTS OF WHICH YOU ARE AWARE THAT HAPPENED IN THE PAST 5 YEARS, BUT WHICH DID NOT RESULT IN AN ACTUAL CLAIM BY OR LOSS. INCLUDE ANY INCIDENTS WHERE YOU CORRECTED YOUR WORK AFTER DELIVERY TO CUSTOMER. / CHECK HERE IF NONE
Date of Incident / Description of Incident / Notice by Customer? / Cost to Correct Work
Please read the statement applicable to your state, and the final statement. Then sign, date and return with your application.
ALASKA: A person who knowingly and with intent to injure, defraud, or deceive an insurance company files a claim containing false, incomplete, or misleading information may be prosecuted under state law.
ARKANSAS: Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison.
CALIFORNIA: For your protection California law requires the following to appear on this form. Any person who knowingly presents false or fraudulent claim for the payment of a loss is guilty of a crime and may be subject to fines and confinement in state prison.
COLORADO: It is unlawful to knowingly provide false, incomplete, or misleading facts or information to an insurance company for the purpose of defrauding or attempting to defraud the company. Penalties may include imprisonment, fines, denial of insurance, and civil damages. Any insurance company or agent of an insurance company who knowingly provides false, incomplete, or misleading facts or information to a policyholder or claimant for the purpose of defrauding or attempting to defraud the policyholder or claimant with regard to a settlement or award payable from insurance proceeds shall be reported to the Colorado division of insurance within the department of regulatory agencies.
DISTRICT OF COLUMBIA: WARNING: It is a crime to provide false or misleading information to an insurer for the purpose of defrauding the insurer or any other person. Penalties include imprisonment and/or fines. In addition, an insurer may deny insurance benefits if false information materially related to a claim was provided by the applicant.
FLORIDA: Any person who knowingly and with intent to injure, defraud, or deceive any insurer files a statement of claim or an application containing any false, incomplete, or misleading information is guilty of a felony of the third degree.
HAWAII: For your protection, Hawaii law requires you to be informed that presenting a fraudulent claim for payment of a loss or benefit is a crime punishable by fines or imprisonment, or both.
KENTUCKY: Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance containing any materially false information or conceals, for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act, which is a crime.
LOUISIANA: Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison.
MAINE: It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the purpose of defrauding the company. Penalties may include imprisonment, fines or a denial of insurance benefits.
MASSACHUSETTS: NOTICE: If you or someone else on your behalf gives us false, deceptive, misleading, or incomplete information that increases our risk of loss, we may refuse to pay claims under any or all of the Optional Insurance Parts and we may cancel your policy. Such information includes the description and the place of garaging of the vehicle(s) to be insured, the names of operators required to be listed and the answers to questions in this application about all listed operators. Check to make certain that you have correctly listed all operators and the completeness of their previous driving records. The Merit Rating Board may verify the accuracy of the previous driving records of all listed operators, including that of the applicant for this insurance.
MINNESOTA: A PERSON WHO SUBMITS AN APPLICATION OR FILES A CLAIM WITH INTENT TO DEFRAUD OR HELPS COMMIT A FRAUD AGAINST AN INSURER IS GUILTY OF A CRIME.
NEW JERSEY FOR AUTO: Any person who includes any false or misleading information on an application for an insurance policy is subject to criminal and civil penalties. FOR WC: I UNDERSTAND THAT ANY INTENTIONAL FALSE OR MISLEADING INFORMATION CONCERNING ANY FACT IN THIS APPLICATION MAY SUBJECT ME TO PENALTIES AS ARE PROVIDED BY LAW.
NEW MEXICO: ANY PERSON WHO KNOWINGLY PRESENTS A FALSE OR FRAUDULENT CLAIM FOR PAYMENT OF A LOSS OR BENEFIT OR KNOWINGLY PRESENTS FALSE INFORMATION IN AN APPLICATION FOR INSURANCE IS GUILTY OF A CRIME AND MAY BE SUBJECT TO CIVIL FINES AND CRIMINAL PENALTIES.
NEW YORK FOR AUTO: ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD ANY INSURANCE COMPANY OR OTHER PERSON FILES AN APPLICATION FOR COMMERCIAL INSURANCE OR A STATEMENT OF CLAIM FOR ANY COMMERCIAL OR PERSONAL INSURANCE BENEFITS CONTAINING ANY MATERIALLY FALSE INFORMATION, OR CONCEALS FOR THE PURPOSE OF MISLEADING, INFORMATION CONCERNING ANY FACT MATERIAL THERETO, AND ANY PERSON WHO IN CONNECTION WITH SUCH APPLICATION OR CLAIM, KNOWINGLY MAKES OR KNOWINGLY ASSISTS, ABETS, SOLICITS OR CONSPIRES WITH ANOTHER TO MAKE A FALSE REPORT OF THE THEFT, DESTRUCTION, DAMAGE OR CONVERSION OF ANY MOTOR VEHICLE TO A LAW ENFORCEMENT AGENCY, THE DEPARTMENT OF MOTOR VEHICLES OR AN INSURANCE COMPANY, COMMITS A FRAUDULENT INSURANCE ACT, WHICH IS A CRIME, AND SHALL ALSO BE SUBJECT TO A CIVIL PENALTY NOT TO EXCEED FIVE THOUSAND DOLLARS AND THE VALUE OF THE SUBJECT MOTOR VEHICLE OR STATED CLAIM FOR EACH VIOLATION. FOR ALL OTHER: 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 insurance act, which is a crime and shall also be subject to a civil penalty not to exceed five thousand dollars and the stated value of the claim for each such violation.
OHIO: ANY PERSON WHO, WITH INTENT TO DEFRAUD OR KNOWING THAT HE IS FACILITATING A FRAUD AGAINST AN INSURER, SUBMITS AN APPLICATION OR FILES A CLAIM CONTAINING A FALSE OR DECEPTIVE STATEMENT IS GUILTY OF INSURANCE FRAUD.
OKLAHOMA:WARNING: Any person who knowingly, and with intent to injure, defraud or deceive any insurer, makes any claim for the proceeds of an insurance policy containing any false, incomplete or misleading information is guilty of a felony.
OREGON: Any person who knowingly and with intent to defraud or solicit another to defraud the insurer by submitting an application containing a false statement as to any material fact, may be violating state law.
PENNSYLVANIA: 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 INSURANCE ACT, WHICH IS A CRIME AND SUBJECTS THE PERSON TO CRIMINAL AND CIVIL PENALTIES.
RHODE ISLAND: In Rhode Island this question must be answered by any applicant for property insurance. Failure to disclose the existence of an arson conviction is a misdemeanor punishable by a sentence of up to one year of imprisonment.
DURING THE LAST TEN YEARS, HAS ANY APPLICANT BEEN CONVICTED OF ANY DEGREE OF THE CRIME OF ARSON?
______YES______NO
TENNESSEE FOR WC: It is a crime to knowingly provide false, incomplete or misleading information to any party to a workers' compensation transaction for the purpose of committing fraud. Penalties include imprisonment, fines and denial of insurance benefits.
FOR ALL OTHER: IT IS A CRIME TO KNOWINGLY PROVIDE FALSE, INCOMPLETE OR MISLEADING INFORMATION TO AN INSURANCE COMPANY FOR THE PURPOSE OF DEFRAUDING THE COMPANY. PENALTIES INCLUDE IMPRISONMENT, FINES AND DENIAL OF INSURANCE BENEFITS.
UTAH FOR WC: Any person who knowingly presents false or fraudulent underwriting information, files or causes to be filed a false or fraudulent claim for disability compensation or medical benefits, or submits a false or fraudulent report or billing for health care fees or other professional services is guilty of a crime and may be subject to fines and confinement in state prison.
VERMONT: Any person who knowingly and with intent to defraud any insurance company or another person files an application for insurance containing any materially false information or conceals for the purpose of misleading information concerning any fact material thereto, may be committing a crime, subjecting the person to criminal and civil penalties.
VIRGINIA: It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the purpose of defrauding the company. Penalties include imprisonment, fines and denial of insurance benefits.
WEST VIRGINIA: Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison.
ALL OTHER STATES: Any person who knowingly and with intent to defraud any insurance company or another person files an application for insurance containing any materially false information, or conceals for the purpose of misleading information concerning any fact material thereto, commits a fraudulent insurance act, which is a crime and subjects the person to criminal and civil penalties. Not applicable in Nebraska.
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