Product Liability Insurance Request

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What is the full legal name of your company?(Required)

If your company is ABC LLC, Enter "ABC LLC", if its ABC Inc, enter "ABC Inc".

If your company has a DBA or trade name what is/are it/they?

If you use any trade names or have any DBAs enter them here.

What type of legal entity is your operation?(Required)

Corporation

Partnership

Sole Proprietor

LLC

Other

How many LLC Members are there?(Required)

if other, please explain.(Required)

What is your Name?(Required)

First Last

Email address?(Required)

Contact phone number?(Required)

What is your Company's Web Address?

Please provide a DETAILED description of all of your business operations.(Required)

What date did your company start?(Required)

MM slash DD slash YYYY

What date do you need coverage to start?(Required)

MM slash DD slash YYYY

What your Mailing Street address?(Required)

Mailing city?(Required)

Mailing State(Required)

Mailing Zip?(Required)

Our physical address different from our mailing address.(Required)

What is the physical street address of your operations?(Required)

This need to be the address that your operations take place at. Do not use PO Boxes, unless your company works out of the post office.

City(Required)

State(Required)

Zip(Required)

Is your operation controlled by, owned by, or commonly owned, affiliated or associated with any other organization?(Required)

If so, please explain.(Required)

Product Classification #1

Tell us all about your products. Be as specific as possible when entering product classes. Specifics are better. If you have several items in the same class, just tell us the class, like "cosmetics" vs lipstick, mascara, and eye liner or "Infant clothing" vs baby shirts, onesies, and infant socks.

If products are manufactured for you, imported from overseas; or bear your company name, please be sure to include the "Manufacturer" class.

Product Classification 1(Required)

Frozen Foods, Spices, Lip Cosmetics, Wearable Electronic Devices, Truck Brakes?

Your company acts as:(Required)

Manufacturer

Wholesaler

Retailer

Importer

Manufacturer's Rep

Your company sells to:(Required)

Wholesalers

Retailers

Consumers

Other

Years in the market?(Required)

Do you install these?(Required)

You service or repair these?(Required)

% of revenue from these?(Required)

Please enter a number from 0 to 100.

Who manufactures these?(Required)

We do

A Third Party Does

What is the name of the entity that manufactures these for you?(Required)

Add a 2nd Product Class?

Yes, Please

Product Classification #2

Product Classification 2(Required)

Your company acts as:(Required)

Manufacturer

Wholesaler

Retailer

Importer

Manufacturer's Rep

Your company sells to:(Required)

Wholesalers

Retailers

Consumers

Other

Years in the market?(Required)

Do you install these?(Required)

You service or repair these?(Required)

% of revenue from these?(Required)

Please enter a number from 0 to 100.

Who manufactures these?(Required)

We do

A Third Party Does

What is the name of the entity that manufactures these for you?(Required)

Add a 3rd Product Class?

Yes, Please

Product Classification #3

Product Classification 3(Required)

Your company acts as:(Required)

Manufacturer

Wholesaler

Retailer

Importer

Manufacturer's Rep

Your company sells to:(Required)

Wholesalers

Retailers

Consumers

Other

Years in the market?(Required)

Do you install these?(Required)

You service or repair these?(Required)

% of revenue from these?(Required)

Please enter a number from 0 to 100.

Who manufactures these?(Required)

We do

A Third Party Does

What is the name of the entity that manufactures these for you?(Required)

Add a 4th Product Class?

Yes, Please

Product Classification #4

Product Classification 4(Required)

Your company acts as:(Required)

Manufacturer

Wholesaler

Retailer

Importer

Manufacturer's Rep

Your company sells to:(Required)

Wholesalers

Retailers

Consumers

Other

Years in the market?(Required)

Do you install these?(Required)

You service or repair these?(Required)

% of revenue from these?(Required)

Please enter a number from 0 to 100.

Who manufactures these?(Required)

We do

A Third Party Does

What is the name of the entity that manufactures these for you?(Required)

Add a 5th Product Class?

Yes, Please

Product Classification #5

Product Classification 5(Required)

Your company acts as:(Required)

Manufacturer

Wholesaler

Retailer

Importer

Manufacturer's Rep

Your company sells to:(Required)

Wholesalers

Retailers

Consumers

Other

Years in the market?(Required)

Do you install these?(Required)

You service or repair these?(Required)

% of revenue from these?(Required)

Please enter a number from 0 to 100.

Who manufactures these?(Required)

We do

A Third Party Does

What is the name of the entity that manufactures these for you?(Required)

Do you have a retail location that you operate out of?(Required)

Yes

Please provide details on the retail space: address, square footage, number of employees.(Required)

Are you serving, sampling, or pouring alcohol?

Yes

Are your products manufactured in a GMP compliant facility?(Required)

Yes

How many PAYROLLED employees does your company have?(Required)

Enter Zero "0" if none. Exclude officers & members if they are not W2 employees. Do not include subcontractors.

What are your estimated total gross sales for the next 12 months, in dollars?(Required)

Only enter numbers, no symbols. Enter ZERO "0" if none

What were last year's total gross sales?(Required)

Only enter numbers, no symbols. Enter ZERO "0" if none

What were the prior year's total gross sales?(Required)

Only enter numbers, no symbols. Enter ZERO "0" if none

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

If so, please provide details:(Required)

Have you discontinued or are you considering discontinuing any product or service listed above?

If so, please provide details:(Required)

Any products or services used in connection with aircraft/missiles/aerospace?(Required)

If so, please provide details:(Required)

Do any products or ingredients or components thereof, originate from outside the United States(Required)

What are the countries of origin of your products or components?(Required)

Provide the name of each foreign manufacturer, distributor or supplier of your products:(Required)

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

If Yes, provide the name(s) and address(es) of your contract manufacturer:(Required)

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

If so, please provide details:(Required)

What percent of your products are manufactured for others?(Required)

Products manufactured for others are....(Required)

Check all that apply

Our formulation

Their formulation

Do you have a quality control and testing procedure?(Required)

If so, how long do you keep quality control and testing records?(Required)

Can you identify your product(s) from those of your competitors?(Required)

Do all records show to whom and the date each product was sold?(Required)

Do you require certificates of insurance evidencing Products Liability Insurance AND naming you as an additional insured, from your suppliers?(Required)

Who designs your products?(Required)

Your company, the manufacturer...?

Are product designs reviewed, tested and verified by others?(Required)

Do you have a Formal program to withdraw known or suspected defective products from the market, AKA a formal Recall Plan?(Required)

Have you ever recalled or are you considering recalling any product?(Required)

Have any of the your products, ingredients or components, 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?(Required)

If so, please provide details:

What "Per Occurrence" liability limit do you need?(Required)

This is the maximum amount that would be paid out for any single claim.

What "Aggregate" liability limit do you need?(Required)

This needs to be equal to or greater than the "Per Occurrence Limit" and is the maximum amount that would be paid out during any single policy period.

What per claim deductible would you prefer?(Required)

Prior Insurance Coverage

Does this company currently have or has had liability insurance in the past?(Required)

What is the name of your prior or current insurer (not your broker)?(Required)

What Per Occurrence liability limit did you have on your current or prior policy?(Required)

If Other, what Aggregate limit did you have on your current or prior policy?(Required)

If Other, what Aggregate liability limit did you have on your current or prior policy?(Required)

What was the deductible on your prior policy?(Required)

What is/was the expiration date of your prior policy, if it passed, what date did coverage end?(Required)

MM slash DD slash YYYY

If you have a "Claims Made: policy it has a retro date, what date is that?

MM slash DD slash YYYY

What is/was the annual premium of the current/prior policy?(Required)

How long have you been continuously insured?(Required)

Why are you looking to replace your current coverage?(Required)

Current policy won't cover my products

Hate my broker

My policy is misclassified - Was sold the wrong insurance

They can't offer me additional coverages I need

Too costly

Other

If other from above(Required)

Date of Loss

MM slash DD slash YYYY

Loss Amount in dollars

Nature of the claim (What caused the claim)?

Final Details

We're almost done here!

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?(Required)

If so, please provide details:(Required)

What is your position in the organization? (President, CEO, CFO, Assistant, Managing Member...)(Required)

Product Labels & Manuals

If the products are topical or ingestible please make sure that any labels include complete ingredient panels. For food products please include the complete nutritional panels.

Drop files here or

Accepted file types: jpg, pdf, png, Max. file size: 100 MB, Max. files: 20.

Do you have specific insurance requirements you need to comply with?(Required)

This is very important. Your vendor agreements may require very specific coverages and endorsements that go beyond basic coverages.

Yes - I will upload them below

Yes - I will paste them below

Insurance Requirements(Required)

Please upload copies of any insurance requirements you may need to satisfy, or previously accepted certificates you have been issued and had accepted.

Drop files here or

Accepted file types: jpg, pdf, png, Max. file size: 100 MB, Max. files: 10.

These are the insurance requirements we need to satisfy.(Required)

Which, if any, are you selling on or through, or plan to in the next 12 months?(Required)

Please let us know what retailers you have agreements with or plan to in the near future.

None of These

Amazon

Bed Bath Beyond

Big5 Sports

Chewy's

Costco

CVS

Dick's Sporting Goods

FitFabFun

Home Depot

HSNi

KeHE

Lowe's

RiteAid

Target

Tractor Supply

UNFI

Walgreens

Walmart

Wayfair

Wholefoods

Prior Insurance

Please attach copies of your prior insurance policy so we can verify coverages as well as effective, expiration, and retroactive dates.

Drop files here or

Accepted file types: pdf, Max. file size: 100 MB, Max. files: 5.

Which other coverages are you interested in or are required to have?

These are important, so don't take them lightly. If you have requirement you may need to satisfy, please take a look and make sure.

Cyber Liability/Data Breach(Required)

Can provide coverage for data breaches, network attacks, cyber fraud, ransomware, social engineering, attack & extortion. Over 50% of small business owners are victims annually, and the average breach can cost upwards of $200 per compromised record, so a breach of as few as 500 clients can cost $100,000.

Yes

Directors & Officers(Required)

insures directors and officers of privately held companies against claims alleging mismanagement of the firm. You may, and should be required to maintain this coverage if you are dealing with outside investors.

Yes

Domestic & International Cargo(Required)

This is not included with product liability. This coverage can provide insurance for your inventory from origin to destination. While in transit internationally, domestically as well as while in 3rd party logistic centers & warehouses. If your inventory is at a 3PL or 3rd party warehouse, they are NOT insuring it for you.

Yes

Employment Practices Liability(Required)

EPLI, or Employment Practices Liability Insurance covers businesses and business owners against claims by workers, employees or ex-employees that their legal rights as employees have been violated. This can include harassment, wrongful termination, discrimination, wage & hour, breach of an employment contract, and even 3rd party claims like the American Disability Act.

Yes

Foreign Product Liability(Required)

A typical American insurance policy covers the U.S., Canada & Puerto Rico. This endorsement can extend your liability coverage territory to include worldwide claims.

Yes

Property & Inventory Coverage(Required)

Product and General liability insurance is a 3rd party coverage, it does not provide coverage for damage to property, real estate, equipment or inventory you own. This coverage provides insurance on the 'things' your company owns in the event that they are damaged or destroyed.

Yes

Product Recall Coverage(Required)

Product Recall provides coverage to assist in the costs associated with recalling a product from the market. Limits over $25,000 will most likely require a formal recall plan be in place.

Yes

Business Income Coverage(Required)

Provides coverage for lost income in the event your business location is damaged or destroyed.

Yes

Workers Compensation(Required)

Workers Compensation is a state mandated coverage that provides no-fault insurance for your employees. Which means that it will pay regardless of fault for employee injuries while on the job. In essence if an employee in injured while performing a work related duty, then Workers Compensation insurance will pay a portion of that employees salary for a specified period of time as well as medical bills. If you have an employee that is injured while on the job, your company will be held liable for these costs.

Yes

Liquor Liability(Required)

Liquor liability insurance helps protect a business that sells, serves, or distributes alcohol. This type of business insurance can help cover claims of bodily injury or property damage that an intoxicated person causes after a company served them alcohol.

Yes

Trade Credit Insurance(Required)

Trade Credit Insurance is a coverage intended to protect against the risk of non-payment when selling goods and services to customers on credit terms.

Yes

Business Income Coverage

How much Business Income coverage would you like?(Required)

This should be enough to cover any and all lost income in the event your business location is damaged or destroyed. So if it would take you 6 months to be up and running after your place of business is destroyed, then this number should be at least 1/2 of your annual gross sales.

Cyber Liability / Data Breach

What Cyber Liability / Data Breach Limit would you like?(Required)

How many individual personal records does your company store?(Required)

0-999

1,000-4,999

5,000-9,999

10,000-49,999

50,000-999,999

1,000,000 or more

Indicate what safeguards you have in place:(Required)

None

Mobile Device Encryption

Network Data Encryption

Compliance with Payment Card Industry Data Security Standards

Up-to-date, active firewall technology

Up-to-date, active anti-virus software on all computers, networks, and mobile devices

A process in place to regularly download and install patches

Backup and recovery procedures in place for all important data

An incident response plan to respond to a network intrusion

A disaster recovery plan, business continuity plan, or equivalent to respond to a computer

system disruption

Controls to ensure the content of media communications and websites are lawful

Multi-factor authentication for remote access to sensitive data

Employment Practices Liability

How many employees do you have?(Required)

What is your annual employee turnover?(Required)

Have you had any layoffs in the last 12 months?(Required)

How may layoffs have you had in the last 12 months?(Required)

Do you have any reason to believe that there is a pending employment practices claim that may arise?(Required)

If so, please provide details as to the nature of this claim.(Required)

Foreign Liability

What percent of your total annual sales do you expect to be foreign sales in the next 12 months?(Required)

Please enter a number from 0 to 100.

Workers Compensation

What is your Federal Tax ID# (FEIN)

If you don't have it handy just say so, we'll send you an email requesting it.

Payroll & Classifications(Required)

Add additional lines for each state & job class

Classification

Location State

Annual Payroll

# of Employees

Domestic & International Cargo

What commodities are you transporting?(Required)

List the Countries and Annual Values Shipped(Required)

Add a new line for each commodity & conveyence

Country Shipped From

Country Shipped To

Commodity Shipped

Annual Values Shipped

What's the MAX. value per any one international shipment(Required)

None

$50,000

$100,000

$250,000

$500,000

$1,000,000

Other

How are your international shipments made(Required)

Air

Vessel

No International Shipping

How are goods being shipped:(Required)

Containerized and /or Air Freight

Breakbulk

Bulk

On Deck

Other

If importer/exporter, how are goods packed?(Required)

What is the value of merchandise you DOMESTICALLY shipping ANNUALLY?(Required)

Enter 0 of Zero

What's the MAX value per any one domestic shipment

None

$50,000

$100,000

$250,000

$500,000

$1,000,000

Other

How are your domestic shipments made

Air

Truck

Railroad

Are you shipping to or from any of the following?(Required)

Afghanistan, Cuba, Iran, Iraq, Jordan, Kenya, Lebanon, Libya, Nigeria, North Korea, Pakistan, Republic of Yemen, Somalia, Sudan, Syria, Russia, the Commonwealth of Independent States (C.I.S.) and countries that formerly comprised the U.S.S.R.

Property / Inventory Coverage

And a new line for each property location

Locations & Values for Property Coverage(Required)

Add a new line for each location and property type. Business property: Property the business owns in the building, furniture, fixtures, machinery... Improvements: permanent additions you have added to the space, Wall coverings, flooring, partitions...

St Address

Zip

Property Value

Prop Type

Burglar Alarm

Fire Alarm

Sprinklers

Location is

Product Recall Coverage

What Product Recall Limit are you seeking?(Required)

$25,000

$100,000

$500,000

$1,000,000

$2,000,000

$3,000,000

$4,000,000

$5,000,000

Recall Types(Required)

What types of recall are you seeking coverage for?

Government Mandated Recalls

Voluntary Recalls

Both Government & Voluntary Recalls

Written Recall Plan

If available, please upload a copy of your written recall plan.

Accepted file types: pdf, doc, docx, rtf, Max. file size: 100 MB.

Liquor Liability

Is there a written policy regarding non-service to minors and obviously intoxicated persons?(Required)

Yes

Have all employees serving alcohol undergone documented alcohol service training program?(Required)

Yes

Liquor Liability Limit(Required)

None

$100,000

$250,000

$300,000

$500,000

$1,000,000

$2,000,000

$3,000,000

$4,000,000

$5,000,000

Trade Credit Insurance

How much Trade Credit Insurance coverage are you seeking?(Required)

$500,000

$1,000,000

$2,000,000

$3,000,000

$4,000,000

$5,000,000

$6,000,000

$7,000,000

$8,000,000

$9,000,000

$10,000,000

Welcome to the Finish Line

How did you hear about us?(Required)

Referred by someone

AOL - Remember AOL?

Google

Facebook

Instagram

Yahoo

An article I read

Radio or TV

One of the Kardashians

You insure something for me

Some dark alley

No freaking clue

Yellow Pages 🤣

If you were referred, who can we thank with a nice gift?(Required)

Please provide any additional information we may not have asked and that you feel might be important for us to know.

You may include additional coverages that you are seeking that were not asked or addressed above.