Products Liability Insurance Application

Products Liability Insurance Application

This application is made by Applicant Name: (the "Applicant") to Proposed Insurer Name: (the "Insurer") for consideration of products liability insurance coverage on the terms and conditions set forth in this application and any attachments.

RECITALS

WHEREAS, the Applicant manufactures, assembles, sells, or distributes the products described in this application and seeks coverage for liability arising out of such products; and

WHEREAS, the Insurer is authorized to underwrite and issue products liability insurance and requires the information and representations in this application to evaluate underwriting, premium and terms for coverage; and

WHEREAS, the Applicant represents that the information provided herein is true, complete, and material to the Insurer's decision to provide coverage.

NOW THEREFORE, in consideration of the Insurer's review and possible issuance of a policy, the Applicant submits the following statements, representations and disclosures which will form the basis of any coverage issued.

1. APPLICANT INFORMATION

2. DESCRIPTION OF PRODUCTS AND OPERATIONS

3. DISTRIBUTION AND SALES

4. LOSS HISTORY AND PENDING MATTERS

In the past five (5) years, has the Applicant had any product-related claims, suits, recalls, or governmental investigations? Yes No

5. REQUESTED COVERAGE

Desired Effective Date:   Requested Per Occurrence Limit: $   Requested Aggregate Limit: $

6. REPRESENTATIONS, WARRANTIES AND AUTHORIZATION

The Applicant represents and warrants that the statements contained in this application and any attachments are true and complete to the best of Applicant's knowledge and that no material facts have been misstated or omitted. The Applicant acknowledges that the Insurer will rely on these statements in determining eligibility for coverage, premium and terms. The Applicant further acknowledges that any material misrepresentation or omission may be a basis for rescission or denial of coverage.

The Applicant authorizes the Insurer to make any inquiry deemed necessary to verify the accuracy of the statements contained herein, including but not limited to inspection of facilities, product testing records, claims files and financial documents. The Applicant agrees to cooperate with the Insurer in connection with any investigation or claim.

7. CONDITIONS OF APPLICATION

Submission of this application does not bind the Insurer to issue a policy nor bind the Applicant to accept any policy that may be offered. Any coverage provided shall be subject to the Insurer's underwriting approval and will be governed by the terms, conditions, definitions and exclusions contained in the policy form and endorsements issued by the Insurer.

The Applicant agrees to provide promptly any additional information requested by the Insurer, including certifications, test reports, or samples, and acknowledges that delays in providing requested information may affect underwriting determination or coverage effective dates.

8. EXCLUSIONS AND LIMITATIONS

The Insurer's policy, if issued, will contain standard exclusions and limitations customary to products liability coverage, which may include, without limitation, exclusions for intentional acts, punitive damages where uninsurable as a matter of law, war, pollution unless endorsed, and liabilities arising from products used in aircraft, watercraft, or motor vehicles where other insurance is primary. The Applicant understands that referenced exclusions will be set forth in the policy language and that no coverage is binding until the policy is issued.

9. NOTICES

All notices pursuant to this application shall be in writing and delivered to the addresses provided herein. Notice of any claim, suit, recall or governmental inquiry affecting any product covered by a policy shall be provided to the Insurer as soon as practicable and in accordance with the notice provisions of the policy.

10. AMENDMENTS, WAIVER, GOVERNING LAW, AND SEVERABILITY

No amendment, waiver or modification of this application shall be valid unless executed in writing by both the Applicant and an authorized representative of the Insurer. Failure of the Insurer to insist upon strict performance of any provision shall not constitute a waiver of such provision or a waiver of the Insurer's rights thereafter.

This application and any policy issued in reliance hereon shall be governed by the substantive laws of the jurisdiction identified in the policy declarations, without regard to its conflicts of law principles. If any provision of this application is found to be unenforceable, the remaining provisions shall remain in full force and effect.

11. ENTIRE AGREEMENT

This application, together with any attachments, exhibits and the policy (if issued), constitutes the entire agreement between the parties with respect to the subject matter hereof and supersedes all prior negotiations, representations and understandings, whether written or oral.

ATTACHMENTS AND FURTHER DOCUMENTATION

Attachments to this application may include product brochures, labels and instructions, test reports, quality control manuals, current policy declarations pages, and a schedule of standard warranties provided to customers. Indicate the attachments provided:

AUTHORIZATION AND CERTIFICATION

By signing below, the Applicant certifies that the statements contained in this application and any attachments are true and complete to the best of the Applicant's knowledge and that no material facts have been omitted. The signatory represents that he or she is authorized to sign on behalf of the Applicant and binds the Applicant to the statements, authorizations and acknowledgements set forth herein.

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