Personal Information
Proposed Effective Date *
|
/ |
|
/ |
|
List all mergers or acquisitions by your company (including subsidiaries) in past 5 years
List all joint ventures in which your company is a partner
Policy / Coverage Information
Current retroactive date
|
/ |
|
/ |
|
Transaction Type
Proposed Retroactive Date *
|
/ |
|
/ |
|
Limits of Liability
Retained Limit
Products & Services
Fiscal Year Begins on *
|
/ |
|
/ |
|
Total estimated gross sales for the following periods
Last Fiscal Year
Current Fiscal Year
Next Fiscal Year
List each product line or service you provide and the related sales *
List each manufactured electronic product, precision instrument, or medical device you make or sell
Income from other business activities
What is the worst thing that could happen to your customers' operations if your product/service were to fail or stop working? *
What is the average life expectancy of each of your products? *
Name your 5 largest customers *
Product Development & Quality Control
Briefly explain your product development methodology *
Describe your quality assurance program *
List all products and quality assurance standards, such as ISO 9000, for which you are certified
Please list all products that you have discontinued making, but which are still being used
If you have ever had to recall a product, please explain the circumstances
Suppliers
Sub & Independent Contractors
What, if any, development or product work do you contract out?
Distribution
State the % of your products that are directly shipped to the following
Marketing / Contracts
Describe the training of your sales staff in terms of teaching them the characteristics and capabilities of your products and services *
General Information
Explain all 'Yes' responses in Remarks section
Prior Incidents
If you are requestion that the retroactive date of this policy be dated prior to the effective date of this policy, provide any information that you know of that may result in a claim being made during the covered period.
Failure to report such information may void coverage in this policy.
Please describe any prior incidents
Date *
|
/ |
|
/ |
|