Product Liability Insurance Quote

Insured Name:

DBA (If applicable)

Mailing Address

City

State

Zip

FEIN:

Yr. Business Started:

Number of Years in Trade:

Website

Email

Business Telephone

Cell:

Number of Owners:

Annual Sales:

Entity Type

Other Legal Status

Is your Physical Address the same as your Mailling Address?

Yes

No

Street Address

City

State

Zip

Do you sell your products on Amazon?

Yes

No

Do any of your products contain CBD?

Yes

No

Are any of your products Ingestible CBD?

Yes

No

Provide the following information for each of the products and/or services for which you would like coverage. Only those products and services listed below will be considered for coverage. If you have more than one product, you can add additional rows.

What are the total annual gross receipts from all products and services listed above?

Are you actively considering any change in the mix of products, including adding new products or services, for the coming year?

Yes

No

If yes, provide details

Have you discontinued or considered discontinuing any product or service listed above?

Yes

No

If yes, provide details

Are any of your products or services used in connection with aircraft/missiles/aerospace?

Yes

No

If yes, provide details

Do any of your products, ingredients, or components thereof originate outside the United States?

Yes

No

List Countries of Origin

Name of each organization manufacturer, distributor, or supplier

Do others manufacture, assemble, package, or install products under your name or label?

Yes

No

If yes, provide the name(s) and address(es) of contract manufacturer(s)

Do you manufacture, assemble, package, or install products for others under their name or label?

Yes

No

If yes, explain

Do you have a quality control and testing procedure?

Yes

No

If yes, how long do you keep quality control and testing records?

Per Occurrence ($)

Annual Aggregate Limit ($)

Deductible ($)

Do you currently have liability insurance?

Yes

No

Insurance Company

Limits of Liability

Have you or your organization been declined, cancelled, or non-renewed for any product liability insurance or any similar insurance?

Yes

No

If yes, provide details

Have you or your organization had any claims for Product or Premises Liability 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.

Are you or any person(s) within your organization(s) aware of any fact, incident, circumstance, situation, condition, defect, or suspected defect which may result in a Products Liability claim?

Yes

No

If yes, provide details

General Products Liability Insurance

Insured Information:

Physical Address

Section 2: Specified products and completed operations

Section 3: Processing and Quality Control

Section 4: Limits of Liability

Section 5: Claims history