Products Liability
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Applicant is
Manufacturer
Distributor
Retailer
Importer
Contractor
Other
Describe Operations
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Any installation, service or repair work performed?
SPECIFIED PRODUCTS AND SERVICES
Products and Services
Applicant acts as a/an
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W
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C
# of Yrs
% of Sales
Does Applicant
Install
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Products Sold To
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M- Manufacturer
W- Wholesaler
R- Retailer
MR- Manufacturers Representative
I- Importer
C- Contractor
GP- General Public
CORPORATE HISTORY
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How many years have you been in business under the present name(s)?
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Prior experience in this business under another name(s)?
Have you acquired or sold any companies? Please provide date of acquisition/sale and types of products manufactured
Please provide details on who is responsible for liabilities before/after the transaction
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No
Have you ever had to or are you planning to recall a product?
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No
Are you planning to add any new products in next 12 months?
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No
Any products discontinued in the past 5 years, including changes to design or ingredients?
LOSS AND QUALITY CONTROL
Yes
No
Do you purchase component parts from others?
Yes
No
Do you receive Certificates of Insurance from these suppliers?
Who installs and/or services your products?
Yes
No
Do others manufacture or package under your name or label?
Yes
No
Do they name you as additional insured under the policy?
Yes
No
Do you manufacture, assemble, package or install products for others under another’s name or label?
Yes
No
Do they name you as additional insured under the policy?
Yes
No
Are written quality control and testing procedures followed?
How can you identify your product from competitors?
Yes
No
Do your records show who supplied the component parts going into your products?
Yes
No
If your products are manufactured to the specifications of your customers, does the customer test the product upon receipt ?
Yes
No
Are your designs subject to independent external review, testing or certification?
Yes
No
Are all instructions, operating manuals, advertisements and warranties reviewed by legal council?
Yes
No
Do you have a specific program to withdraw known or suspected defective products from the market?
IF YOU ARE A MANUFACTURER’S REPRESENTATIVE, RETAILER, DISTRIBUTOR OR WHOLESALER
Yes
No
Do you receive a Certificate of Insurance from the Manufacturer?
Yes
No
Are you named as an additional insured under the manufacturer’s policy?
Yes
No
Do you repackage or assemble the product?
Yes
No
Any imported products or components?
Country of origin:
Yes
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Do any products bear your brand name or label?
Yes
No
Are all products obtained from U.S. domestic suppliers?
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