FARM EQUIPMENT MANUFACTURERS ASSOCIATION - FEMA APPLICATION FOR PRODUCT LIABILITY INSURANCE

Transcription

1 Proposed Effective Date FARM EQUIPMENT MANUFACTURERS ASSOCIATION - FEMA APPLICATION FOR PRODUCT LIABILITY INSURANCE Please answer all questions. If not applicable, please indicate N/A. I. Applicant information 1. Full legal name and address of applicant 2. Form of organization Corporation Partnership Sole Proprietor Other 3. Description of operations 4. List full name of all entities which are additional named insureds and indicate their relationship to the named insured 5. Contact name to arrange inspection of your operations Name Title Phone number/fax number address 6. Main contact for day-to-day operations Name Phone number/fax number address Website address 7. List other locations where manufacturing operations are conducted 8. Number of years under present name 9. Have you ever engaged in this or similar operations under a different name? (If so, explain.)

2 II. Products and Completed Operations 1. Products List - Please be specific PRODUCTS OR SERVICE # OF YEARS PRODUCT BUILT APPLICANT IS: M - Manufacturer D - Distributor I - Importer PROJECTED CURRENT YEAR 1ST PRIOR YEAR 2ND PRIOR YEAR 3RD PRIOR YEAR 4TH PRIOR YEAR FOREIGN DOES APPLICANT INSTALL/ SERVICE/REPAIR 2

3 2. Have any of your products been discontinued? (If yes, list product and sales history for at least 5 years) 3. Are any new products planned for the upcoming year? (If yes, please describe products and provide estimated sales and a photo or brochure of new product) 4. Will any currently manufactured products be discontinued? (If yes, please identify discontinued product) 5. Have any of your products been recalled due to a known or suspected defect to the product? (If yes, explain) 6. Can your product be identified from your competitor's products? (If yes, explain) 7. Do you retain liability for any products which you no longer control? (If yes, explain) 8. Have any products or entities been acquired by merger or acquisition? Date of acquisition Did you assume liability for these products? (If yes, explain) 9. Are any of your products used in connection with aircraft, missiles or aerospace? (If yes, explain) 10. Do you import products or component parts? (If yes, identify products) 11. Have any of your products ever been subject to inquiry or investigation by a governmental agency due to product safety? (If yes, explain) 12. Are your products designed, tested, labeled and manufactured to meet or exceed industry or governmental standards? (If not, explain) 3

4 III. Current and Prior Insurance Carrier Information 1. Please complete the following: CURRENT # OF YEARS 1ST PRIOR # OF YEARS 2ND PRIOR # OF YEARS Carrier Limit of Liability Deductibles/SIR Claims Made Retroactive Date 3. Expiration date of current policy 4. Has any carrier ever canceled, restricted or refused to renew your product liability insurance? (not applicable in Missouri) (If yes, explain) 5. Do you require certificates of insurance from your suppliers? Are minimum limits acceptable? 6. Have you been self-insured or had a self-insured retention (SIR)? Who adjusted the claims & established reserves? IV. Proposed Insurance Plans 1. Insurance requested Limit of Liability $ Deductible/SIR $ Retroactive Date V. Claims History 1. Provide currently valued Product Liability loss data for the current year and at least 5 years of claim data from prior carriers to include: Incident reports where no claims have yet been filed. Newspaper clippings and narrative by the applicant. Claim reports that include: Date of loss Report date Description of accident and injuries Claim reserves, payments and loss expenses 2. If there is no loss activity, include a statement on your company letterhead. 4

5 VI. Additional Information 1. Do others manufacture, assemble, package or install products under your name or label? (If yes, explain) 2. Do you manufacture, assemble, package or install products for others under their name? (If yes, explain) 3. Are written quality control & testing procedures followed? (If not, explain) 4. How long are quality control & testing records kept? 5. Do your records indicate when each product was manufactured? (If not, explain) 6. Do your records show the purchaser name & date sold? (If not, explain) 7. Do your records show who supplied the component parts used in your products? (If not, explain) 8. Who designs your products? 9. Are designs reviewed, tested and verified by others? 10. Do you maintain records of changes in designs, advertisements and sales brochures? (If yes, how long?) 11. Are all instructions, operating manuals, advertisements and warranties periodically reviewed by legal counsel to avoid misunderstandings relative to product safety or intended use? 12. List your memberships in any industry product-standard organizations 13. Do you have a specific program to withdraw known or suspected defective products from the market? 14. Do you have a written procedure for the handling of complaints about your products and procedure to report accidents or injuries resulting from your product? (If yes, how long are records maintained?) 15. List the individual or department responsible for handling and maintaining these records. 16. What is your affiliation with FEMA? Member Not a member Associate member 5

6 Application must include the following Your most current 12-month financial statement (balance sheet and income statement). Brochures, catalogs, labels, and service agreements for all products manufactured or distributed by your company. Please have the application signed and dated by an owner, partner or officer. To the best of my knowledge, the information contained in this application is correct and accurate. Date: Signed: Title: Please complete the appropriate Broker or Agent information below (broker - not applicable in Florida). Broker Firm/Agency Name: Broker Name: Telephone Number: FAX Number: Address: Sales Rep Company Name: Sales Rep: Telephone Number: FAX Number: Address: Sentry Insurance a Mutual Company FLORIDA FRAUD STATEMENT (please complete if applicable) ANY PERSON WHO KWINGLY 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. Florida requires that the Insurance Company Name, legibly printed Company Representative's Name and Company Representative's ID number be completed. Insurance Company Name: Sentry Insurance a Mutual Company Company Representative Name: License ID: Company Representative Signature: Return completed form to: Bob Bonifas, CPCU Account Executive FEMA Product Liability Insurance Program National Accounts/Sentry Insurance 1800 North Point Drive Stevens Point WI Phone (715) FAX (715)

7 FRAUD STATEMENTS THIS TICE IS PART OF YOUR APPLICATION FOR: TYPE OF INSURANCE GENERAL STATEMENT Any person who knowingly and with intent to defraud any insurance company or another 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 the person to criminal and [NY: substantial] civil penalties. (Not applicable in CO, DC, FL, HI, KS, MA, MN, NE, OH, OK, OR, VT or WA; in LA, ME, TN, and VA, insurance benefits may also be denied) APPLICABLE IN COLORADO 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 of award payable from insurance proceeds shall be reported to the Colorado Division of Insurance within the Department of Regulatory Agencies. APPLICABLE IN THE DISTRICT OF COLUMBIA WARNING: 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. APPLICABLE IN FLORIDA 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. APPLICABLE IN HAWAII For your protection, Hawaii law requires you to be informed that presenting a fraudulent claim for payment of a loss or benefit is a crime punishable by fines or imprisonment, or both. APPLICABLE IN KANSAS 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 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. APPLICABLE IN MASSACHUSETTS, NEBRASKA, OREGON AND VERMONT Any person who knowingly and with intent to defraud any insurance company or another 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, may be committing a fraudulent insurance act, which may be a crime and may subject the person to criminal and civil penalties. APPLICABLE IN MINNESOTA Any person who files a claim with intent to defraud or helps commit a fraud against an insurer is guilty of a crime. APPLICABLE IN OHIO Any person who, with intent to defraud or knowing that he/she is facilitating a fraud against an insurer, submits an application or files a claim containing a false or deception statement is guilty of insurance fraud. ACORD 63 (2010/07) Page 1 of ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD 7

8 FRAUD STATEMENTS (continued) APPLICABLE IN OKLAHOMA WARNING: 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. APPLICABLE IN 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. APPLICANT'S SIGNATURE DATE (MM/DD/YYYY) ACORD 63 (2010/07) Page 2 of 2 8

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10 Complete this section if quotation for CGL - Premises/Operations Liability is requested. Proposed Effective Date FARM EQUIPMENT MANUFACTURERS ASSOCIATION - FEMA GENERAL LIABILITY ADDENDUM 1. Full legal name & address of applicant 2. Current General Liability Insurance Company name 3. Current Liability Insurance limits or attach current policy declarations page General Aggregate Limit $ Personal & Advertising Injury Limit $ Each Occurrence Limit $ Fire Damage Limit $ Medical Expense Limit $ Employee Benefits Liability Limit $ 4. List any forms & endorsements included in current General Liability policy or include copies of these forms and endorsements 5. Provide details of General Liability claims or incidents which may result in a claim (if none, state None) 6. Location of premises & operations to be covered Location Number Address Description of Operations $ $ $ $ $ $ Gross Sales per Location 7. What is you affiliation with FEMA? Member Not a member Associate Member 10

11 Application must include the following Your most current 12-month financial statement (balance sheet and income statement). Brochures, catalogs, labels, and service agreements for all products manufactured or distributed by your company. Please have the application signed and dated by an owner, partner or officer. To the best of my knowledge, the information contained in this application is correct and accurate. Date: Signed: Title: Please complete the appropriate Broker or Agent information below (broker - not applicable in Florida). Broker Firm/Agency Name: Broker Name: Telephone Number: FAX Number: Address: Sales Rep Company Name: Sales Rep: Telephone Number: FAX Number: Address: Sentry Insurance a Mutual Company FLORIDA FRAUD STATEMENT (please complete if applicable) ANY PERSON WHO KWINGLY 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. Florida requires that the Insurance Company Name, legibly printed Company Representative's Name and Company Representative's ID number be completed. Insurance Company Name: Sentry Insurance a Mutual Company Company Representative Name: License ID: Company Representative Signature: Return completed form to: Bob Bonifas, CPCU Account Executive FEMA Product Liability Insurance Program National Accounts/Sentry Insurance 1800 North Point Drive Stevens Point WI Phone (715) FAX (715)

12 FRAUD STATEMENTS THIS TICE IS PART OF YOUR APPLICATION FOR: TYPE OF INSURANCE GENERAL STATEMENT Any person who knowingly and with intent to defraud any insurance company or another 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 the person to criminal and [NY: substantial] civil penalties. (Not applicable in CO, DC, FL, HI, KS, MA, MN, NE, OH, OK, OR, VT or WA; in LA, ME, TN, and VA, insurance benefits may also be denied) APPLICABLE IN COLORADO 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 of award payable from insurance proceeds shall be reported to the Colorado Division of Insurance within the Department of Regulatory Agencies. APPLICABLE IN THE DISTRICT OF COLUMBIA WARNING: 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. APPLICABLE IN FLORIDA 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. APPLICABLE IN HAWAII For your protection, Hawaii law requires you to be informed that presenting a fraudulent claim for payment of a loss or benefit is a crime punishable by fines or imprisonment, or both. APPLICABLE IN KANSAS 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 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. APPLICABLE IN MASSACHUSETTS, NEBRASKA, OREGON AND VERMONT Any person who knowingly and with intent to defraud any insurance company or another 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, may be committing a fraudulent insurance act, which may be a crime and may subject the person to criminal and civil penalties. APPLICABLE IN MINNESOTA Any person who files a claim with intent to defraud or helps commit a fraud against an insurer is guilty of a crime. APPLICABLE IN OHIO Any person who, with intent to defraud or knowing that he/she is facilitating a fraud against an insurer, submits an application or files a claim containing a false or deception statement is guilty of insurance fraud. ACORD 63 (2010/07) Page 1 of ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD 12

13 FRAUD STATEMENTS (continued) APPLICABLE IN OKLAHOMA WARNING: 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. APPLICABLE IN 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. APPLICANT'S SIGNATURE DATE (MM/DD/YYYY) ACORD 63 (2010/07) Page 2 of 2 13

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