EUROPEAN-AMERICAN INC.

PRODUCTS LIABILITY Insurance Questionnaire
Please complete and return to EurAm
Company Name Street
Type of Applicant City
Telephone: County
Telefax: State / Zip
Website: e-mail
  Federal Employer ID Number
 
2. Are you a:
Other (Specify)
3. How long have you been in business? years    
4. Sales (Split between U.S. and non-U.S.)
a) Estimated (ensuing year)
$
   
b) Last 3 years:
$
$
$
 
$
$
$
5. Products Description:    
a) Give a complete description of each product, including the end user.
b) Identify products acquired through acquisition or merger, those planned for introduction during the next 12 months, and those previously discontinued and date discontinued.
c) Identify the years involved with each product
 
PRODUCTS
YEARS INVOLVED
PRINCIPAL END USE
% OF GROSS SALES
6. Losses
Furnish claims history for the last 5 years. Note: For additional space, click here
 
YEAR 1
YEAR 2
YEAR 3
YEAR 4
YEAR 5
Date of occurrence
Date of claim filed
Describe occurrence & injury or damage
Amount paid $
Amount reserved $
Deductible $
Status of claim

 

a) Are you aware of any other incidents which may result in claims against you? YES NO
b) Are any of your products sold under another's name or label? YES NO
c) Do you package under a trade name other then your own? YES NO

PLEASE EXPLAIN ALL OF THE "YES" ANSWERS, BELOW:

 

7. Existing Insurance Coverage:
a) Has any insurance company ever refused to issue, or canceled your Products or General Liability insurance?
YES
NO
If yes, provide full details:
b) Who is your current Products or General Liability insurer(s)?
c) What Annual Premium and /or rate is charged for this coverage? $
d) What deductibles or self insured retensions apply? $

 

8. Required Insurance Coverage for Products Liability:
Each Occurrence $
Products & Completed Operations Aggregate $
Umbrella / Excess Liability $

Note: If a quotation for umbrella liability is desired, a separate application is required!

9. Please supply any additional information you feel important:

 

Note: Completion of this application does not constitute a binder or obligate the applicant to purchase this insurance.

Desired Effective Date:    
Name: Title: Date:

 

SUPPLEMENTAL QUESTIONS

Explain all "yes" responses (for any past or present product or operation).
1) Does applicant install, service or demonstrate products? YES NO
2) Foreign products sold, distributed, used as components? YES NO
3) Research and development conducted or new products planned? YES NO
4) Guarantees, warranties, hold harmless agreements? YES NO
5) Products related to aircraft / space indusrty? YES NO
6) Products recalled, discontinued, changed? YES NO
7) Products of others sold or re-packaged under applicant label? YES NO
8) Products under label of others? YES NO
9) Vendors coverage required? YES NO
10) Does any named insured sell to other named insureds? YES NO
     
GENERAL INFORMATION
Explain all "yes" responses (for any past or present product or operation).    
11) Any medical facilities provided or medical professionals employed or contracted? YES NO
12) Any exposure to radioactive / nuclear materials? YES NO
13) Do/have past, present, or discontinued operations involve (d) storing, treating, discharging, applying, disposing, or transporting of hazardous material? (e.g. landfill, wastes, fuel tanks, etc.) YES NO
14) Any operations sold, acquired or discontinued in last 5 years? YES NO
15) Machinery or equipment loaned or rented to ohers? YES NO
16) Any watercraft, docks, floats owned/rented? YES NO
17) Any parking facilies owned/rented? YES NO
18) Is a fee charged for parking? YES NO
19) Recreation facilities provided? YES NO
20) Is there a swimming pool on the premises? YES NO
21) Sporting or social events sponsored? YES NO
22) Any structural alterations contemplated? YES NO
23) Any demolition esposure contemplated? YES NO
24) Has applicant been active in or is currently active in joint ventures? YES NO
25) Do you lease employees to or from other employers? YES NO
26) Is there a labor interchange with any other business or subsidiaries? YES NO
27) Are day care facilities operated or controlled? YES NO
28) Have any crimes occurred or been attempted on your premises within the last 3 years? YES NO
29) Is there a formal, written safety and security policy in effect? YES NO
30) Does the business promotional literature make any representations about the safety or security of the premises? YES NO
     
If yes, provide full details: