Product Liability Insurance Quote

Company Name*
Doing Business As (DBA)*
Physical Address*
No PO box allowed

Street Address Address Line 2 City State ZIP Code
Mailing Address*
Same as physical

Street Address Address Line 2 City State ZIP Code
Website
Provide a link to your website or online storefront
Contact Name*
First Last
Email*
Phone Number*
Business Ownership*
- Corporation
- Partnership
- Sole Proprietorship
- Limited Liability Company
- Other
Date business established*
mm/dd/yyyy
MM slash DD slash YYYY
Referral Code
If you were referred to us please provide the referral code.
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)	How many years?	Install, Repair or Service?	Products sold to	Actions

There are no Products.

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
MM slash DD slash YYYY
Retroactive Date (if applicable)
mm/dd/yyyy
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.
Max. file size: 128 MB.
Hidden
Date
MM slash DD slash YYYY

Product Liability Insurance Quote

Product Liability Insurance Quote Application

Step 1 of 4 - General Info

Annual Gross Sales

PROCESSING AND QUALITY CONTROL

INSURANCE INFORMATION

CLAIMS HISTORY