Product Liability Insurance Quote

Company Name*
Doing Business As (DBA)*
Website
Provide a link to your website or online storefront
Mailing Address Line 1*
Address Line 2
City*
State*
Zipcode*
Check this box if there is a different physical address:
Physical Address Line 1*
Address Line 2
City*
State*
Zipcode*
Contact Name*
First Last
Email*
Phone Number*
Business Ownership*
- Corporation
- Partnership
- Sole Proprietorship
- Limited Liability Company
- Other
Date business established*
mm/dd/yyyy
Date Format: MM slash DD slash YYYY
Is your business controlled by, owned by, or commonly owned, affiliated or associated with any other organization?*
- Yes
- No
If yes, provide details (1)

INSURANCE INFORMATION
Provide coverage limits desired or required by your customers
Limits of Liability: Indicate the limits of liability requested:*
Each Occurrence Limit*
Annual Aggregate Limit ($)*
Deductible ($)*
Do you currently have liability insurance?*
- Yes
- No
Present Insurance Company*
Current Limits of Liability*
Expiring Premium*
Expiration Date*
mm/dd/yyyy
Date Format: MM slash DD slash YYYY
Retroactive Date (if applicable)
mm/dd/yyyy
Date Format: MM slash DD slash YYYY
CLAIMS HISTORY
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
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
- No
If yes (7)*
please provide the date of loss, how much was paid, and whether the claim is open or closed.
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
- No
If yes, provide details of expected claims*
As part of this application you can attach product brochures; labels; and Instructions.
Date
Date Format: MM slash DD slash YYYY

PRODUCTS AND OPERATIONS