• Name
• Principal Business Address
• List the names of all predecessor organizations of the Applicant
• Audit Contact Name
• Phone Number
• Website Address
• Date Established
• Applicant is a CorporationPartnershipSole ProprietorshipLimited Liability Company (LLC)Other
• Is the Applicant controlled by, owned by, or commonly owned, afiliated or associated with any other organization?  Yes No
• If Yes, provide details

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

Products and Goods 1

• Products and Goods (or specific categories)
• Applicant acts as a(n) ManufacturerWholesalerRetailerImporterManufacturer's Rep
• Number of Years
• % of Gross Receipts
• Does Applicant install?  Yes No
• Does Applicant repair or service?  Yes No
• Products and Goods sold to WholesalerRetailerConsumer DirectOther

Products and Goods 2

• Products and Goods (or specific categories)
• Applicant acts as a(n) ManufacturerWholesalerRetailerInporterManufacturer's Rep
• Number of Years
• % of Gross Receipts
• Does Applicant install?  Yes No
• Does Applicant repair or service?  Yes No
• Products and Goods sold to WholesalerRetailerConsumer DirectOther

Products and Goods 3

• Products and Goods (or specific categories)
• Applicant acts as a(n) ManufacturerWholesalerRetailerInporterManufacturer's Rep
• Number of Years
• % of Gross Receipts
• Does Applicant install?  Yes No
• Does Applicant repair or service?  Yes No
• Products and Goods sold to WholesalerRetailerConsumer DirectOther

Total gross receipts from all products, goods and services listed above. herinabove:

• Estimated annual gross receipts for the coming year
• Annual gross receipts last twelve months

Does the Applicant have any operations, and/or any receipts or income from any products, goods or services, NOT listed above?  Yes No

• If Yes, provide a detailed explanation.

• Provide the following for ALL products, goods, services and operations.

• Estimated annual gross receipts for the coming year.
• Annual gross receipts:
• Last twelve months
• 1st year prior

• Is the Applicant presently considering any change in the mix of products, goods, services and/or operations, including adding new products, goods, services or operations, for the coming year?
   Yes No

• If Yes, provide details.

• Has the Applicant discontinued or is it considering discontinuing any product or service listed above?  Yes No

• If Yes, provide details.

• Are any of the Applicant’s products or services used in connection with aircraft/missiles/aerospace?
   Yes No

• If Yes, provide details.

• Processing

• Do any products or ingredients or components thereof, originate from outside the United States?
   Yes No

• If Yes, specify:
• Country(ies) of origin
• The name of each manufacturer, distributor or supplier

• Do others manufacture, assemble, package or install products under Applicant's name or label?
   Yes No

• 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 No

• If Yes, explain

• Quality Control and Recordkeeping

• Does the Applicant have a quality control and testing procedure?  Yes No

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

• Can the Applicant identify its product(s) from those of competitors?  Yes No

• Do all records show to whom and the date each product was sold?  Yes No

• Does the Applicant require certificates of insurance evidencing Products Liability Insurance from suppliers?  Yes No

• Who designs the Applicant's products?

• Are product designs reviewed, tested and verified by others?  Yes No

• Does the Applicant have a specific program to withdraw known or suspected defective products from the market?  Yes No

• Has the Applicant ever recalled or is it considering recalling any product?  Yes No

• If Yes, please explain.

• Have any of the Applicant's products or ingredients or components thereof, ever been the subject of any investigation, enforcement action, or notice of violation of any kind by any governmental, quasi-governmental, administrative, regulatory or oversight body?  Yes No

• If yes, provide details.

• Limits of Liability: Indicate the limits of liability requested $ / $
• Deductible: Indicate the deductible requested $

• THE COMPANY DOES NOT GUARANTEE TO OFFER ANY OF THE ABOVE LIMITS AND/OR DEDUCTIBLES.

• Provide the following for present Product Liability Insurance:  None

• Insurance Company
• Limits of Liability
• Deductible/SIR
• Premium
• Expiration Dates (MM/DD/YYYY)
• Retroactive/Prior Acts Date

• Has any insurer declined, canceled, or nonrenewed any Product Liability Insurance or any similar insurance on behalf of any person(s) or organization(s) proposed for this insurance?  Yes No

• If Yes, Provide Details.

• Has any claim for Product Liability been made against any person(s) or organization(s) proposed for this insurance during the last five (5) years?  Yes No

• If Yes, provide five (5) year loss history for all claims, including any predecessor. Attach a description of any loss greater than $10,000.

• 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 Product Liability claim, such that would fall under the proposed insurance?  Yes No

• If Yes, provide details.

As part of this application attach the following: Brochures; Labels; and Instructions.

NOTICE TO THE APPLICANT - PLEASE READ CAREFULLY

No fact, incident, circumstance, situation, condition, defect or suspected defect indicating the probability of a claim or action for which coverage may be afforded by the proposed insurance is now known by any person(s) or organization(s) proposed for this insurance other than that which is disclosed in this application. It is agreed by all concerned that if there is knowledge of any such fact, incident, circumstance, situation, condition, defect or suspected defect any claim subsequently emanating therefrom shall be excluded from coverage under the proposed insurance.

This application, information submitted with this application and all previous applications related hereto and material changes to any of the foregoing of which the underwriting manager, Company and/or affiliates thereof receives notice is on file with the underwriting manager, Company and/or affiliates thereof and is considered physically attached to and part of the policy if issued. The underwriting manager, Company and/or affiliates thereof will have relied upon this application and all such attachments in issuing the policy.

For the purpose of this application, the undersigned authorized agent of the person(s) and organization(s) proposed for this insurance declares that to the best of his/her knowledge and belief, after reasonable inquiry, the statements in this application and in any attachments, are true and complete. The underwriting manager, Company and/or affiliates thereof are authorized to make any inquiry in connection with this application. Signing this application does not bind the Company to provide or the Applicant to purchase the insurance.

If the information in this application and any attachment materially changes between the date this application is signed and the effective date of the policy, the Applicant will promptly notify the underwriting manager, Company and/or affiliates thereof, who may modify or withdraw any outstanding quotation or agreement to bind coverage.

If the policy for which application is made is for claims made coverage, the undersigned declares that the person(s) and organization(s) proposed for this insurance understand that coverage for which this application is made applies:

(i) Only to "claims" first made during the "policy period"; unless an extended reporting period is exercised. If an extended reporting period is exercised, the policy shall also apply to "claims" first made during the extended reporting period; and

(ii) Unless amended by endorsement, the limits of liability contained in the policy shall be reduced, and may be completely exhausted by “claim expenses” and, in such event, the Company will not be liable for “claim expenses” or the amount of any judgment or settlement to the extent that such costs exceed the limits of liability in the policy and unless amended by endorsement, “claim expenses” shall be applied against the “deductible”.

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. I/We authorize the release of claim information from any prior insurer to the underwriting manager, Company and/or affiliates thereof.

RE:
Risk ID. No.:

You are hereby notified that under the Terrorism Risk Insurance Act of 2002 (the “Act”), effective November 26, 2002, and extended on December 22, 2005, that you now have a right to purchase insurance coverage for losses arising out of acts of terrorism, as defined in Section 102(1) of the Act (“Terrorism Coverage”): The term “act of terrorism” means any act that is certified by the Secretary of the Treasury, in concurrence with the Secretary of State, and the Attorney General of the United States—to be an act of terrorism; to be a violent act or an act that is dangerous to human life, property; or infrastructure; to have resulted in damage within the United States, or outside the United States in the case of an air carrier or vessel or the premises of a United States mission; and to have been committed by an individual or individuals acting on behalf of any foreign person or foreign interest, as part of an effort to coerce the civilian population of the United States or to influence the policy or affect the conduct of the United States Government by coercion.

You should know that Terrorism Coverage required to be offered by the Act for losses caused by certified acts of terrorism is partially reimbursed by the United States under a formula established by federal law. Under this formula, the United States pays 90% (85% in 2007) of covered terrorism losses exceeding the statutorily established deductible paid by the insurance company providing the coverage. The premium charged for this Terrorism Coverage is provided below and does not include any charges for the portion of loss covered by the federal government under the Act.

Please indicate whether you would elect to purchase Terrorism Coverage.

Alaska, Florida, Georgia and Oklahoma Applicants: Please be advised that in the event a policy is purchased, the policy premium will include a 1% surcharge for Terrorism Coverage unless you elect to decline Terrorism Coverage. You need to enter an "X” below if you wish to decline Terrorism Coverage.

•  I hereby elect to purchase the Terrorism Coverage required to be offered under the Act. I understand that my policy premium will include a 3% surcharge for this coverage. I decline to purchase the Terrorism Coverage required to be offered under the Act. I understand that my policy will be endorsed to exclude the Terrorism Coverage required to be offered under the Act.