Breathe - Product Liability Application HiddenEZLynxAppIDCompany Name:*AddressStreet Address*City*State*ALAKAZARCACOCTDEFLGAHIIDILINIAKSKYLAMEMDMAMIMNMSMOMTNENVNHNJNMNYNCNDOHOKORPARISCSDTNTXUTVTVAWAWVWIWYDCZip Code*Telephone:*Fax:*Email:* Website:* Legal Status:* Individual Partnership Corporation Joint Venture Contact Name:* First Last Phone:*List the names of all predecessor organizations of the Applicant:*Federal Tax ID Number:*Number of years in business:*Is the Applicant controlled by, owned by, or commonly owned, affiliated, or associated with any other organization?* Yes No If yes, provide details:*Total years of experience in this type of business:*Please state the number of full-time employees:*Please state the number of part-time employees:*Product or Service #1 for which the Applicant wants coverage:*For Product or Service #1, Applicant acts as which of the following:* Manufacturer Wholesaler Retailer Importer Manufacturer's Rep. Product or Service #1 - Number of Years:*Product or Service #1 - Percentage of Gross Receipts:Does the Applicant install Product #1?* Yes No Does Applicant repair or service Product #1?* Yes No Does Applicant repair or service Product #1?* Yes No Product or Service #1 are sold to:* Wholesaler Retailer Consumer Direct Are there other Products or Services for which Applicant wants coverage?* Yes No Product or Service #2 for which the Applicant wants coverage:*For Product #2, Applicant acts as which of the following:* Manufacturer Wholesaler Retailer Importer Manufacturer's Rep. Product or Service #2 - Number of Years:*Product or Service #2 - Percentage of Gross Receipts:*Does the Applicant install Product #2?* Yes No Does Applicant repair or service Product #2?* Yes No Product or Service #2 are sold to:* Wholesaler Retailer Consumer Direct Are there other Products or Services for which Applicant wants coverage?* Yes No Product or Service #3 for which the Applicant wants coverage:*For Product #3, Applicant acts as which of the following:* Manufacturer Wholesaler Retailer Importer Manufacturer's Rep. Product or Service #3 - Number of Years:*Product or Service #3 - Percentage of Gross Receipts:*Does Applicant repair or service Product #3?* Yes No Product or Service #3 are sold to:* Wholesaler Retailer Consumer Direct Are there other Products or Services for which Applicant wants coverage?* Yes No Product or Service #4 for which the Applicant wants coverage:*For Product #4, Applicant acts as which of the following:* Manufacturer Wholesaler Retailer Importer Manufacturer's Rep. Product or Service #4 - Number of Years:*Product or Service #4 - Percentage of Gross Receipts:*Does the Applicant install Product #4?* Yes No Does Applicant repair or service Product #4?* Yes No Product or Service #4 are sold to:* Wholesaler Retailer Consumer Direct Estimated annual gross receipts for the coming year (for all products and services listed above):*Annual gross receipts for the last 12 months (for all products and services listed above):*Annual gross receipts for the first prior year (for all products and services listed above):*Is the Applicant presently considering any change in the mix of products, including adding new products or services, for the coming year?* Yes No If yes, provide details:*Has the Applicant discontinued or is it considering discontinuing any product or service listed above?* Yes No If yes, provide details:*Are any of the Applicant’s products or services used in connection with aircraft/missiles/aerospace?* Yes No If yes, provide details:*Do any products, ingredients, or components thereof originate outside the United States?* Yes No If yes, please specify the country(ies) of origin:*If yes, please specify the name of each organization manufacturer, distributor, or supplier:*Do others manufacture, assemble, package or install products under the Applicant’s name or label?* Yes No If yes, provide the name(s) and address(es) of contract manufacturer(s):*Does the Applicant manufacture, assemble, package, or install products for others under their name or label?* Yes No If yes, explain:*Does the Applicant have a quality control and testing procedure?* Yes No If yes, how long does the Applicant keep quality control and testing records?*Can the Applicant identify its product(s) from those of competitors?* Yes No Do all records show to whom and the date each product was sold?* Yes No Does the Applicant require certificates of insurance evidencing Products Liability Insurance from suppliers?* Yes No Who designs the Applicant's products?*Are product designs reviewed, tested, and verified by others?* Yes No Does the Applicant have a specific program to withdraw known or suspected defective products from the market?* Yes No Has the Applicant ever recalled or is it considering recalling any product?* Yes No Have the Applicant’s products, ingredients, or components thereof ever been the subject of any investigation, enforcement action, or notice of violation of any kind by any governmental, quasi-governmental, administrative, regulatory, or oversight body?* Yes No If yes, provide details:*Are all the products sold considered “Generally Regarded Safe” by the FDA?* Yes No Do you import any products from other countries?* Yes No If yes, please list countries:*Do you export products or have foreign operations?* Yes No If yes, please provide details:*Do you make or sell any of the following:* Select All Vitamins/Supplements Acetone Products Aerosol Products Invasive Body Inks Electric Curlers/Straighteners None of the Above Do you make or handle any products that are explosive, flammable, or poisonous either by itself or in combination with other materials?* Yes No Could any of your products be classified as pharmaceuticals?* Yes No If yes, please provide details:*Do others private-label your products?* Yes No If yes, please provide details:*Limits of Liability Requested:*Deductible:*Do you currently have liability insurance?* Yes No Insurance Company:*Current Limits of Liability:*Deductible/SIR:*Expiring Premium:*Expiration Date:* MM slash DD slash YYYY Retroactive Date/Prior Acts Date (if applicable):* MM slash DD slash YYYY Has any insurer declined, cancelled, or nonrenewed any product liability insurance or any similar insurance on behalf of any person(s) or organization(s) proposed for this insurance?* Yes No If yes, please provide details:*Has any claim for Product Liability been made against any person(s) or organization(s) proposed for this insurance during the last 5 years?* Yes No If yes, please complete the following for the previous five (5) years, including for any predecessor. Attach a description of any loss greater than $10,000 total incurred.Year #1:*Number of Claims in Year #1:*Total Amounts Paid in Year #1:*Amounts Reserved in Year #1:*Total Incurred for Year #1:*Date of Loss (Year #1)* MM slash DD slash YYYY Year #2:*Number of Claims in Year #2:*Total Amounts Paid in Year #2:*Total Amounts Paid in Year #2:*Amounts Reserved in Year #2:*Total Incurred for Year #2:*Date of Loss (Year #2)* MM slash DD slash YYYY Year #3:*Number of Claims in Year #3:*Total Amounts Paid in Year #3:*Amounts Reserved in Year #3:*Total Incurred for Year #3:*Date of Loss (Year #3):* MM slash DD slash YYYY Year #4:*Number of Claims in Year #4:*Total Amounts Paid in Year #4:*Amounts Reserved in Year #4:*Total Incurred for Year #4:*Date of Loss (Year #4):* MM slash DD slash YYYY Year #5:*Number of Claims in Year #5:*Total Amounts Paid in Year #5:*Amounts Reserved in Year #5:*Total Incurred for Year #5:*Date of Loss (Year #5):* MM slash DD slash YYYY Is (are) any person(s) or organization(s) proposed for this insurance aware of any fact, incident, circumstance, situation, condition, defect, or suspected defect which may result in a Products Liability claim?* Yes No If yes, please provide details:*Do you want coverage for your business personal property/inventory?*YesNoHow much coverage do you want? (example $10,000, $50,0000, $100,000)*
