Product Liability Insurance Quote

Section 1: Company details

Company Name

Please specify

Mailing Address

Street Address

City

State

Zip

Is your Physical Address the same as your Mailling Address?

Yes

Physical Address

Street Address

City

State

Zip

Business Telephone

Fax

Website

Legal Status

Other Legal Status

Contact Name

Contact Phone

List the names of all predecessor organizations of the Applicant

Federal Tax ID Number

Number of years in business

How did you hear about us?

Please tell us how you were referred

Does the applicant have a policy with Insurance Canopy currently?

Yes

Section 2: Specified products and completed operations

Provide the following information for those products and/or services for which the Applicant wants coverage. Only those products and services listed below will be considered for coverage.

Total gross receipts from all products and services listed above:

Estimated annual gross receipts for the coming year ($)

Is the Applicant presently considering any change in the mix of products, including adding new products or services, for the coming year?

Yes

If yes, provide details

Has the Applicant discontinued or is it considering discontinuing any product or service listed above?

Yes

If yes, provide details

Are any of the Applicant’s products or services used in connection with aircraft/missiles/aerospace?

Yes

If yes, provide details

Do any of your products contain CBD?

Yes

Do any of your products have ingestible CBD exposure?

Yes

What Percentage of Sales:

Do you source your CBD from legally grown hemp plants as described in the H. R. 2 Agricultural Improvement Act of 2018?

Yes

Section 3: Processing and Quality Control

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

Yes

List Countries of Origin

Name of each organization manufacturer, distributor, or supplier

Do others manufacture, assemble, package, or install products under the Applicant’s name or label?

Yes

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

Does the Applicant manufacture, assemble, package, or install products for others under their name or label?

Yes

If yes, explain

Does the Applicant have a quality control and testing procedure?

Yes

If yes, how long does the Applicant keep quality control and testing records?

Section 4: Limits of Liability

Limits of Liability requested:

The company does not guarantee to offer any of the requested limits and/or deductibles.

Per Occurrence ($)

Annual Aggregate Limit ($)

Deductible ($)

Do you currently have liability insurance?

Yes

Insurance Company

Limits of Liability

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, provide details

Section 5: Claims history

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 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.

Is (are) any person(s) or organization(s) proposed for this insurance aware of any fact, incident, circumstance, situation, condition, defect, or suspected defect which may result in a Products Liability claim?

Yes

If yes, provide details

General Products Liability Insurance

Section 1: Company details

Mailing Address

Physical Address

Section 2: Specified products and completed operations

Section 3: Processing and Quality Control

Section 4: Limits of Liability

Section 5: Claims history