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Product Liability Insurance Quote
Product Liability Insurance Quote 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 6 - General Info
16%
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
*
SELECT
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
Zipcode
*
Check this box if there is a different physical address:
Physical Address Line 1
*
Address Line 2
City
*
State
*
SELECT
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
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)
PRODUCTS AND OPERATIONS
Provide the following information for those products, goods and/or services you want coverage for. Only those products, goods and services listed below will be considered for coverage.
Describe your product or category
*
You act as a(n)
*
Manufacturer
Wholesaler
Retailer
Importer
Manufacturer's rep.
Consumer
How many years?
*
% of Gross Receipts
*
Do you
Install?
Repair or Service?
Products sold to
*
Wholesaler
Retailer
Consumer Direct
Other
Do you want to add an additional product or category
*
Yes
No
Describe your product or category
*
You act as a(n)
*
Manufacturer
Wholesaler
Retailer
Importer
Manufacturer's rep.
How many years?
*
% of Gross Receipts
*
Do you
Install?
Repair or Service?
Products sold to
*
Wholesaler
Retailer
Consumer Direct
Other
Do you want to add an additional product or category
*
Yes
No
Describe your product or category
*
You act as a(n)
*
Manufacturer
Wholesaler
Retailer
Importer
Manufacturer's rep.
Consumer
How many years?
*
% of Gross Receipts
*
Do you
Install?
Repair or Service?
Products sold to
*
Wholesaler
Retailer
Consumer Direct
Other
Annual Gross Sales
from all products and services entered before
Estimated for the coming year ($)
*
enter gross receipts, before any deductions
In the last 12 months ($)
*
enter 0 if no prior sales
In first prior year ($)
*
enter 0 if no prior sales
Are you presently considering any change in the mix of products, including adding new products or services, for the coming year?
*
Yes
No
If yes, provide details (2)
*
Have you discontinued or considering discontinuing any product or service listed above?
*
Yes
No
If yes, provide details (3)
*
Are any of your products or services used in connection with aircraft/missiles/aerospace?
*
Yes
No
If yes, provide details (4)
*
PROCESSING AND QUALITY CONTROL
List countries of origin for your products, ingredients, or components
*
(i.e. USA, China, Mexico, European Union, etc)
Do OTHERS manufacture, assemble, package, or install products under YOUR name or label?
*
Yes
No
Name of each organization manufacturer, distributor, or supplier
*
Do YOU manufacture, assemble, package, or install products for others under THEIR name or label?
*
Yes
No
If yes, explain (5)
*
Do you have a quality control and testing procedure?
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Yes
No
If yes, how long do you keep quality control and testing records?
*
Can you identify your product(s) from those of competitors?
*
Yes
No
Do all records show the date of purchase and to whom each product was sold?
*
Yes
No
Who designs the products you sell?
*
Are product designs reviewed, tested, and verified by others?
*
Yes
No
Do you have a specific program to withdraw known or suspected defective products from the market
*
Yes
No
Have you ever recalled or presently considering recalling any product?
*
Yes
No
If yes, provide details (6)
*
Have your products, ingredients, or components thereof ever been the subject of any investigation, enforcement action, or notice of violation of any kind by any government, quasi-government, administrative, regulatory, or oversight body?
*
Yes
No
If yes, provide details (7)
*
INSURANCE INFORMATION
Provide coverage limits desired or required by your customers
Limits of Liability: Indicate the limits of liability requested:
*
$1,000,000 / $2,000,000 (most common, meets Amazon requirements)
$2,000,000 / $2,000,000
Need other limits
Each Occurrence Limit
*
Annual Aggregate Limit ($)
*
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
