Product Liability Insurance Quote

Products Liability Application

Product Liability Insurance covers liability incurred by a manufacturer, importer, wholesaler, retailer or distributor because of an injury or property damage resulting from the use of their product. Complete this application to get free no obligation product liability insurance quotes from top U.S. carriers.

Step 1 of 5

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Date Today

Business Name(Required)

Mailing Address:(Required)

Street Address Address Line 2 City State ZIP Code

Location Address (no PO box)(Required)

Same as mailing address above

Street Address Address Line 2 City State ZIP Code

Applicant is:(Required)

Individual

Limited Liability Company

Corporation

Partnership

Joint Venture

Other

Please provide details about Other business entity(Required)

Website Address:(Required)

Inspection Contact Full Name:(Required)

E-mail Address:(Required)

Phone Number:(Required)

How many years have you been in business?

Gross sales for 2022

Product Name(Required)

Gross sales for 2022(Required)

Number of Claims Paid During This Year(Required)

Enter 0 if no claims

Amount in Claims Paid This Year(Required)

Enter 0 if no claims

Amount Reserved for Claims This Year(Required)

Enter 0 if no claims

Insurer's Name(Required)

Gross sales for 2021

Product Name(Required)

Gross sales for 2021(Required)

Number of Claims Paid During This Year(Required)

Enter 0 if no claims

Amount in Claims Paid This Year(Required)

Enter 0 if no claims

Amount Reserved for Claims This Year(Required)

Enter 0 if no claims

Insurer's Name(Required)

Gross sales for 2020

Product Name(Required)

Gross sales for 2020(Required)

Number of Claims Paid During This Year(Required)

Enter 0 if no claims

Amount in Claims Paid This Year(Required)

Enter 0 if no claims

Amount Reserved for Claims This Year(Required)

Enter 0 if no claims

Insurer's Name(Required)

Gross sales for 2019

Product Name(Required)

Gross sales for 2019(Required)

Number of Claims Paid During This Year(Required)

Enter 0 if no claims

Amount in Claims Paid This Year(Required)

Enter 0 if no claims

Amount Reserved for Claims This Year(Required)

Enter 0 if no claims

Insurer's Name(Required)

Gross sales for 2018

Product Name(Required)

Gross sales for 2018(Required)

Number of Claims Paid During This Year(Required)

Enter 0 if no claims

Amount in Claims Paid This Year(Required)

Enter 0 if no claims

Amount Reserved for Claims This Year(Required)

Enter 0 if no claims

Insurer's Name(Required)

36. What are the estimated sales for the next 12 months?(Required)

38. Does risk engage in the generation of power, other than emergency back-up power, for their own use or sale to power companies?(Required)

YES

-- Describe how your business is engaged in the generation of power, other than emergency back-up power, for your own use or sale to power companies:(Required)

39. Does applicant have other business ventures for which coverage is not requested?(Required)

YES

-- Provide details about other business ventures:(Required)

40. Has any insurer ever canceled, nonrenewed, declined or refused to issue products liability insurance to the applicant?(Required)

YES

-- Explain why prior product liability insurance was ever canceled, nonrenewed, declined or refused:(Required)

Use below field to provide any additional comments

(for example if you need to add an additional insured, provide name and address for the certificate of insurance, etc)

Final Step. Scroll down.
This application does not bind the applicant nor the Company to complete the insurance, but it is agreed that the information contained herein shall be the basis of the contract should a policy be issued.

FRAUD WARNING:

Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information or conceals for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act, which is a crime and subjects such person to criminal and civil penalties. (Not applicable in AL, CO, DC, FL, KS, LA, ME, MD, MN, NE, NY, OH, OK, OR, RI, TN, VA, VT or WA.) NOTICE TO ALABAMA APPLICANTS: Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or who knowingly presents false information in an application for insurance is guilty of a crime and may be subject to restitution fines or confinement in prison, or any combination thereof.

NOTICE TO COLORADO APPLICANTS: It is unlawful to knowingly provide false, incomplete, or misleading facts or information to an insurance company for the purpose of defrauding or attempting to defraud the company. Penalties may include imprisonment, fines, denial of insurance, and civil damages. Any insurance company or agent of an insurance company who knowingly provides false, incomplete, or misleading facts or information to a policy holder or claimant for the purpose of defrauding or attempting to defraud the policy holder or claimant with regard to a settlement or award payable from insurance proceeds shall be reported to the Colorado Division of Insurance within the Department of Regulatory Agencies.

WARNING TO DISTRICT OF COLUMBIA APPLICANTS: It is a crime to provide false or misleading information to an insurer for the purpose of defrauding the insurer or any other person. Penalties include imprisonment and/or fines. In addition, an insurer may deny insurance benefits if false information materially related to a claim was provided by the applicant.

NOTICE TO FLORIDA APPLICANTS: Any person who knowingly and with intent to injure, defraud, or deceive any insurer files a statement of claim or an application containing any false, incomplete, or misleading information is guilty of a felony of the third degree.

NOTICE TO KANSAS APPLICANTS: Any person who, knowingly and with intent to defraud, presents, causes to be presented or prepares with knowledge or belief that it will be presented to or by an insurer, purported insurer, broker or any agent thereof, any written, electronic, electronic impulse, facsimile, magnetic, oral, or telephonic communication or statement as part of, or in support of, an application for the issuance of, or the rating of an insurance policy for personal or commercial insurance, or a claim for payment or other benefit pursuant to an insurance policy for commercial or personal insurance which such person knows to contain materially false information concerning any fact material thereto; or conceals, for the purpose of misleading, information concerning any fact material thereto, commits a fraudulent insurance act, which is a crime and subjects such person to criminal and civil penalties.

NOTICE TO LOUISIANA APPLICANTS: Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison.

NOTICE TO MAINE APPLICANTS: It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the purpose of defrauding the company. Penalties may include imprisonment, fines or a denial of insurance benefits.

NOTICE TO MARYLAND APPLICANTS: Any person who knowingly or willfully presents a false or fraudulent claim for payment of a loss or benefit or who knowingly or willfully presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison.

NOTICE TO MINNESOTA APPLICANTS: A person who files a claim with intent to defraud or helps commit a fraud against an insurer is guilty of a crime.

NOTICE TO OHIO APPLICANTS: Any person who, with intent to defraud or knowing that he is facilitating a fraud against an insurer, submits an application or files a claim containing a false or deceptive statement is guilty of insurance fraud.

NOTICE TO OKLAHOMA APPLICANTS: Any person who knowingly, and with intent to injure, defraud or deceive any insurer, makes any claim for the proceeds of an insurance policy containing any false, incomplete or misleading information is guilty of a felony.

NOTICE TO RHODE ISLAND APPLICANTS: Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison.

FRAUD WARNING (APPLICABLE IN VERMONT, NEBRASKA AND OREGON): Any person who intentionally presents a materially false statement in an application for insurance may be guilty of a criminal offense and subject to penalties under state law.

FRAUD WARNING (APPLICABLE IN TENNESSEE, VIRGINIA AND WASHINGTON): It is a crime to knowingly provide false, incomplete, or misleading information to an insurance company for the purpose of defrauding the company. Penalties include imprisonment, fines, and denial of insurance benefits.

NEW YORK AUTOMOBILE FRAUD WARNING: Any person who knowingly and with intent to defraud any insurance company or other person files an application for commercial insurance or a statement of claim for any commercial or personal insurance benefits containing any materially false information, or conceals for the purpose of misleading, information concerning any fact material thereto, and any person who, in connection with such application or claim, knowingly makes or knowingly assists, abets, solicits or conspires with another to make a false report of the theft, destruction, damage or conversion of any motor vehicle to a law enforcement agency, the department of motor vehicles or an insurance company, commits a fraudulent insurance act, which is a crime, and shall also be subject to a civil penalty not to exceed five thousand dollars and the value of the subject motor vehicle or stated claim for each violation.

NEW YORK OTHER THAN AUTOMOBILE FRAUD WARNING: Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information, or conceals for the purpose of misleading, information concerning any fact material thereto, commits a fraudulent insurance act, which is a crime, and shall also be subject to a civil penalty not to exceed five thousand dollars and the stated value of the claim for each such violation.

APPLICANT'S STATEMENT:(Required)

I have read the above application and I declare that to the best of my knowledge and belief all of the foregoing statements are true, and that these statements are offered as an inducement to us to issue the policy for which I am applying. (Kansas: This does not constitute a warranty.)

APPLICANT NAME(Required)

APPLICANT TITLE(Required)

APPLICANT'S SIGNATURE(Required)

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Paperless Insurance Services, Inc

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625 46TH AVE

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San Francisco, CA 94121

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Dmitriy Glazer