Canyon Crest Insurance Application

Section 1: Company Details

Named Insured as it is to appear on the policy

Doing Business As (DBA)

Street Address

City

State

Zip

Telephone

Fax

Website

Other legal status

Address of operation

City

State

Zip

Name of Owner or Insurance Contact:

Federal tax ID

Years in business

Years of experience

Full-time employees

Part-time employees

Section 2: Product and sales data

Please list products you manufacture and distribute. Provide breakdown of sales for each product

Sales Exposure Information (in $):

Next 12 months (Projected)

Year

Domestic Sales

US, Canada & US Territories

Foreign Sales

outside of US Territories

Total Sales

Last 12 months (Expiring)

Year

Domestic Sales

US, Canada & US Territories

Foreign Sales

outside of US Territories

Total Sales

1st Prior

Year

Domestic Sales

US, Canada & US Territories

Foreign Sales

outside of US Territories

Total Sales

Section 3: Insurance Information

Please indicate the limits of liability desired: (i.e., $1,000,000 each occurrence, $2,000,000 aggregate, and $2,000,000 product liability)

Each Occurrence: $

Aggregate: $

Product Liability: $

Do you currently have Liability Insurance?

Yes

Insurance Company:

Limits of Liability: $

Deductible/SIR: $

Expiring Premium: $

Expiration Date:

Retroactive Date:

Please request loss runs/claims history from your current insurance company.

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

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

If yes, please provide details:

Section 4: Manufacturing and Distribution

Are all the products sold considered Generally Regarded Safe by the FDA?

Yes

Do you import any products from other countries?

Yes

If yes, please list Countries:

Do you export products or have foreign operations?

Yes

If yes, please provide details:

Do you make or sell any of the following products?

Do you make or handle any products that are explosive, flammable, or poisonous either by itself or in combination with other materials?

Yes

Could any of your products be classified as pharmaceuticals?

Yes

If yes, please provide details:

Do others private-label your products?

Yes

If yes, please provide details:

Section 5: Marketing

Percentage of Total Sales to:

Wholesalers (%)

Distributors (%)

Your Storefront (%)

Online (%)

Do you hold harmless your suppliers of materials, bottles, ingredients, etc.?

Yes

Do your suppliers insure you under their product liability policy?

Yes

Do you require distributors of your product to hold you harmless?

Yes

Do you require distributors of your product to obtain their own product liability insurance?

Yes

Section 6: Loss Prevention

Have your products ever been investigated for safety by any government agency?

Yes

If yes, please provide details:

Do you have a written products recall plan?

Yes

If yes, please attach a copy.

Have you ever recalled products because of a potential product safety hazard?

Yes

If yes, please indicate percent of recovery:

If yes, please provide details:

Do you have a written products safety program?

Yes

If yes, please attach a copy.

Section 7: Property Coverage

Underwriting Information:

Construction Type:

Frame/Brick Veneer

Masonry

Metal

Yr. Built:

# Stories:

Square Footage:

Is building over 25 years old?

None

Yes

Year of updates for heating

Year of updates for electrical

Year of updates for roof

Year of updates for plumbing

Miles from the Fire Station:

Feet from the Hydrant:

Is the building sprinklered (Fire Suppression System)?

Yes

If Yes, what percentage:

Do you have an alarm?

Yes

If Yes, what type?

Local Gong

Central Station

Fire and/or Burglar

Is property located within 5 miles of any coast?

Yes

Coverage Information:

Requested Effective Date:

Coverage Information:

Building - If Owned

Limit of Insurance

Deductible

Policy Form

Co-Insurance

Valuation

Business Personal Property

Limit of Insurance

Deductible

Policy Form

Co-Insurance

Valuation

Income

Limit of Insurance

Deductible

Policy Form

Co-Insurance

Valuation

Lien Holders/Mortgage Holders:

Prior Carrier/Claims:

Current Insurance Carrier:

Number of Yrs. Insured:

Expiring Premium:

Have you had any claims in the past 5 years?

None

Yes

If you answered Yes, please provide the following information:

Section 8: Product Design and Quality Control

Do you do your own formulating and design your work?

Yes

Do you maintain records of design changes and reasons justifying these changes?

Yes

Are your designs subject to independent external review, testing, or certification?

Yes

Are your products manufactured and labeled to meet or exceed all government/industry standards?

Yes

Are warranties obtained from all suppliers?

Yes

Are quality control records kept so that you can identify at a later date what tests you applied to a given product at a given time?

Yes

Section 9: Instruction / Warnings / Advertising / Warranties

Do warning labels comply with federal statutory warning labeling requirements?

Yes

Does all product labeling comply with FDA guidelines?

Yes

Do you expressly disclaim or limit warranties for your products?

Yes

Do you provide any specific training/instructions for the user in the proper use of your product?

Yes

Section 10: Loss Control and Defense

Can you determine, based on available records, for all products you have sold:

a. When any given product was manufactured?

Yes

b. To whom it was sold and the date of sale?

Yes

c. Who supplied parts and supplies in the final product?

Yes

Do you maintain copies of old instruction or operation manuals and advertising material?

Yes

Section 11: Accident Procedure

Do you have a manual for obtaining data about product complaints/accidents/injuries?

Yes

Does your procedure provide for examining and preserving any allegedly defective product, with the results of such examination recorded?

Yes

Section 12: Additional Information

How many vehicles are registered in the name of the business?

How many vehicles are rented/leased by owners for business purposes or under business name?

For what purpose are the vehicles rented/leased?

Errands

Sales

Delivery/Pick-up

Other

Other vehicle purpose

What is the average length of the hired/borrowed period for these vehicles?

How many employees do you have?

How many contractors do you have?

How many representatives do you have?

Number of employees/contractors/representatives using their own vehicles for company business:

How often do they drive their own vehicles for company business?

None

Occasional

Full-time

For what purpose?

Errands

Sales

Delivery/Pick-up

Other

Other driving purpose

Do you currently have Workers Compensation coverage?

Yes

If yes, what is the expiration date of your policy?

Are you interested in getting a quote for Business Income or Property coverage?

Yes

If you already have this coverage, when does it expire?

Comments:

Warranty:

I/We warrant to the Company, that I/We understand and accept the notice stated above and that the information contained herein is true and that it shall be the basis of the policy and deemed incorporated therein, should the Company evidence its acceptance of this application by issuance of a policy.

Note: This application is signed by undersigned authorized agent of the Applicant(s) on behalf of the Applicant(s) and its owners, partners, directors, officers, and employees.

Date:

Signature:

Print Name:

Title: