PRODUCTS LIABILITY APPLICATION

Applicant Is: Individual  Corporation   Partnership    Joint Venture   Limited Liability Company   Other

  1. Limit Desired:

  2. Deductible Desired:

  7. (a). Do you compound ingredients?................................................................................................... No Yes

(b). Do you package the product?..................................................................................................... No Yes

  8.   Are all products sold under your label?.............................................................................................. No Yes

  9. Do you manufacture the product?...................................................................................................... No Yes

If no, what component parts are purchased?

 10. Is any of your work subcontracted to others?................................................................................... No Yes

If so, state type and percentage:

 11. Are any parts purchased from foreign manufacturers?........................................................................ No Yes

 12.  Do you assemble the product?......................................................................................................... No Yes

 13. (a). Has the product been tested by Underwriters Laboratories?........................................................... No Yes

 (b). Is it UL listed?........................................................................................................................... No Yes

 14.  What percentage of sales are for replacement parts?.........................................................................%

 15.  Has your product ever been subject to any inquiry or investigation by any governmental agency

      concerning the efficiency, adequacy of labeling, hazardous contents or safety?..................................... No Yes

If yes, attach full details and result of such inquiry.

 16. Do you maintain and/or service the products?.................................................................................... No Yes

(a). If yes, attach full details including copy of your standard written service contract and gross receipts from this source.

(b). Do you maintain complete inventory records of shipments and/or deliveries to
consignees?.............................................................................................................. No Yes

(c). Can the date of manufacture of each product be identified by the factory number stamped on it?.... No Yes

(d). Have you ever recalled any of your products for any reason?.................................. No Yes

If yes, attach details.

(e). Are serial and/or batch numbers shown on the finished product and on shipment
invoices?................................................................................................................... No Yes

(f). Do you keep samples of products involved in your quality control procedures?....... No Yes

If yes, how long are samples retained?

(g). Do you have a products recall plan?......................................................................... No Yes

If yes, attach description.

 17. Is original installation of products performed by your employees?........................................................ No Yes

 18. If no, does the installer supply parts not manufactured by you?........................................................... No Yes

 19. Are any of your products subject to deterioration?.............................................................................. No Yes

 20. Are any of your products inflammable or explosive?........................................................................... No Yes

If yes, attach details.

 21. Do you issue guarantees or warranties to purchasers?....................................................................... No Yes

If so, for what periods do you guarantee or warrant your products?

Attach full details and copy of your form of guarantee or warranty.

 22. Do you agree to hold dealers, distributors or suppliers harmless against claims or suits for bodily injury

      or property damage in connection with your products?........................................................................ No Yes

If yes, attach copies of your standard forms.

 23. Are any of the above dealers, etc., affiliated with you?........................................................................ No Yes

 24. If you are a distributor, are you insured by the manufacturer?.............................................................. No Yes

 25. Is your product used by aircraft industry?.......................................................................................... No Yes

 26. (a) How many years have you been in business under the present name?

(b). Have any of the principals ever engaged in this or similar enterprises under a different name?........... No Yes

If yes, attach details.

 27. Do you plan to manufacture any new products to be marketed within the next 12 months?.................... No Yes

If yes, attach description.

 28. Have you ceased to manufacture any products during the past five years?........................................... No Yes

If yes, attach description and sales by year.

 29. If any products are accompanied by any written brochure, labels, instructions or other written statements, attach
copies.

 30. Show sales for five years: (Attach list if necessary)

 31. What are the estimated sales for this year?  $

Give claims history in following form or equivalent (five years) (Amounts shown should be from the ground up)

 32. Has any insurer ever canceled or refused to issue or renew your products liability insurance?................ No Yes

If yes, why?

This application does not bind the applicant nor the Company to complete the insurance, but it is agreed that the information contained herein shall be the basis of the contract should a policy be issued.

FRAUD WARNING:

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 such person to criminal and civil penalties.

FRAUD WARNING (APPLICABLE IN TENNESSEE AND WASHINGTON):

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.

FRAUD WARNING APPLICABLE IN THE STATE OF NEW YORK:

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.

APPLICANT NAME AND TITLE:

APPLICANT’S SIGNATURE:________________________________________________________________ DATE:______________

(Must be signed by active owner, partner or executive officer)

PRODUCER’S SIGNATURE:________________________________________________________________ DATE:______________

AGENT NAME:

AGENT LICENSE NUMBER:

(Applicable to Florida Agents Only)

IOWA LICENSED AGENT:

(Applicable in Iowa Only)