Chubb Group of Insurance Companies

Transcription

1 Chubb Group of Insurance Companies Continuum From Chubb Timely Liability Solutions Applications for: Discontinued Products Liability Insurance Successor Liability Insurance Retroactive Liability Insurance

2 APPLICATION FOR CONTINUUM LIABILITY INSURANCE GENERAL INFORMATION 1. a. Applicant Name: _ b. Mailing Address: _ c. Website Addresses: d. Applicant is: corporation joint venture partnership individual other (describe): e. If publicly traded, symbol/exchange: f. Year business established: Place of incorporation/organization: g. Is Applicant a subsidiary of another organization? Yes No If yes, explain: h. Has any legal or trade name of the Applicant changed (including the last 10 years)? Yes No If yes: I. Any bankruptcies or liens against the Applicant or other parties to the transaction? Yes No If yes: 2. Producer: Number: 3. Has any insurer ever cancelled or refused to renew any coverage? Yes No If yes, explain: TRANSACTION INFORMATION Describe the circumstances or transactions leading to this Application for insurance. Include separate attachments as necessary. Applicant s role in the transaction: Buyer Seller other (explain): Describe the transaction: discontinuation of business or product or service line total purchase/sale or merger purchase or sale of all or substantially all assets of the acquired entity purchase or sale of less than substantially all assets of the acquired entity other (describe): Page 2 of 14

3 COVERAGE REQUEST Limit requested (all coverages subject to General Liability a single Limit Of Insurance): products liability premises / operations liability other: Deductible / Retention requested: Each Claim / Event Excess Liability products liability premises / operations liability Limit requested (all coverages subject to a single Limit Of Insurance): automobile liability. employer s liability other: Excess Liability - Please complete and attach Schedules Of Underlying Insurance as requested herein. Injury or Offense Period Injury or Offense Period is the period during which a covered injury or offense would occur (future) or would have occurred (past). From: Claim Reporting Period Claim Reporting Period is the period during which the first report of a covered claim would be made (future) to the insured or insurer (in no case earlier than the date we agree to bind coverage). From: To: To: EXPOSURE INFORMATION 1. Describe all businesses, operations and products (current and prior) potentially exposing the Injury or Offense Period including complete descriptions of all applicable entities. Include separate attachments as necessary. Page 3 of 14

4 2. Describe any assets, businesses, entities, operations, products or services that have been (or to be) discontinued, divested or sold (including the last 10 years). Indicate year discontinued, divested or sold as well as expected product/project life spans and quantify the number of products/projects estimated still viable and in use. Include separate attachments as necessary. Year Transaction Type / Description Product / Project Life Span Cumulative Amount Still Viable And In Use 3. With respect to any discontinued, divested or sold assets, businesses, entities, operations, products or services, describe any liabilities that have been assumed or retained by the Applicant. 4. If liabilities have been assumed by or transferred to others, describe by whom, how and the extent to which such others are responsible. 5. If coverage is requested in connection with operations or products of an entity that has been (or to be) discontinued, divested or sold by the Applicant, then indicate if coverage is to apply only to the Applicant as the insured or to both the Applicant and the acquiring entity as insureds? 6. Describe and quantify any incomplete or unsold inventory at the time of this transaction. Indicate the disposition plans for any such inventory. Page 4 of 14

5 SALES: List sales for each year of the Injury or Offense Period. YEAR U.S.A. / CANADA SALES OTHER COUNTRY SALES TOTAL SALES # OF UNITS Name other countries by sales volumes: PRODUCTS - Please explain all answers as requested. Include separate attachments as necessary. Attach copies of product brochures/catalogues and marketing materials (current and those used during the Injury or Offense Period.) 1. Expected product life spans: Years Months. Explain: 2. Any products or services in connection with aircraft/aerospace or watercraft? Yes No 3. Any products used in connection with automobiles, other vehicles or mobile equipment? Yes No 4. Any products or services in connection with nuclear or other energy-related facilities? Yes No 5. Explosive or flammable products? Yes No 6. Contaminative, pathogenic, toxic / poisonous or other pollutant or hazardous products? Yes No 7. Any products containing asbestos, silica, lead or other hazardous materials? Yes No 8. Any workplace safety products or services? Yes No 9. Any drug, medical device, dietary supplement or cosmetics related products or services? Yes No Page 5 of 14

6 10. Any alcohol, firearm or tobacco related products or services? Yes No 11. Any children s products or services? Yes No 12. Foreign sourced products distributed in the U.S.A., or used as components / ingredients? Yes No 13. Any products or services discontinued (including for safety or other reasons)? Yes No CONTRACTS / INSTALLATIONS / SERVICE WORK - Please explain all answers as requested. Include separate attachments as necessary. 1. Describe any installation, repair, service or other contract work. Include separate attachments as necessary, listing projects and related revenues for the last 10 years. 2. All contract work by Applicant or with subcontractors supported by formal written contracts? Yes No If no, why not? 3. Any work subcontracted to others? Yes No If yes, describe what types and amount work?: 4. All contracts with subcontractors, suppliers and vendors reviewed by legal counsel? Yes No If no, why not?: 5. All contracts with subcontractors and suppliers require indemnity to the Applicant and holding the Applicant harmless from legal action? Yes No If no, explain: 6. Subcontractors and suppliers required to carry insurance (at least GL and Workers Compensation)? Yes No If yes, what types / limits? If no, why not? 7. Subcontractors and suppliers required to provide the Applicant with insured status on their insurance? Yes No If no, explain: 8. Subcontractors and suppliers required to provide certificates of insurance to the Applicant? Yes No If no, explain: 9. Any construction, demolition or structural alteration work? Yes No 10. Blasting, earth moving, excavation, mining or other underground work? Yes No 11. Maritime, reservoir or other waterway or water supply work? Yes No 12. Bridge, dam, railroad or tunnel work? Yes No Page 6 of 14

7 13. Any work involving asbestos, silica, lead or other pollutants or hazardous materials? Yes No 14. Architects, engineers, surveyors or other professionals employed or contracted? Yes No POLLUTION - Please explain all answers as requested. Include separate attachments as necessary. 1. Any environmental or regulatory agency (U.S.A. or otherwise) identified or investigated any party as a generator, transporter, storer, treater or disposer of hazardous materials? Yes No 2. Any underground storage tanks at any location (current or past)? Yes No 3. Any landfills or other waste facilities? Yes No OTHER EXPOSURES - Please explain all answers as requested. Include separate attachments as necessary. 1. Aircraft owned? Yes No Non-owned Aircraft? Yes No 2. Watercraft owned? Yes No Non-owned Watercraft? Yes No 3. Ownership, operation, maintenance or use of any railroad or rail equipment? Yes No 4. Any exposure to nuclear/radioactive or other hazardous materials? Yes No 5. Any uses of genetic engineering or nanotechnology? Yes No 6. Any healthcare professionals employed or contracted or health care facilities? Yes No 7. Any law enforcement or security services? Yes No 8. Any accounting or legal services? Yes No 9. Any financial or insurance services? Yes No 10. Any independent contractors engaged? Yes No 11. Any employees/workers contracted from or to another entity? Yes No 12. Any liability assumed under contract or agreement? Yes No 13. Child care or other special care facilities operated or sponsored? Yes No _ Page 7 of 14

8 14. Any business or operations located outside the U.S.A.? Yes No _ 15. Any special events or sponsored activities? Yes No _ LOSS PREVENTION/PRODUCT RECALL PLANS AND CONTROLS Please explain all answers as requested. Include separate attachments as necessary. 1. Does the Applicant have in place formal Loss Prevention and Quality Control Programs? Yes No Attach copies of programs or explain below. 2. All advertising materials, instruction manuals, packaging and warning labels reviewed by Yes No legal counsel? If no, why not?: 3. Describe how to identify and distinguish products from similar (competitors) products at time of loss: 4. Describe how to identify and quantify products by date of manufacture and sale at time of loss: 5. Does the Applicant maintain records of: a) when and where products were manufactured Yes No b) to whom products were sold and the date of sale Yes No c) who supplied components and ingredients going into products Yes No d) quality control and product/material tests Yes No Describe record keeping practices: by whom, where and for how long records are maintained, including maintenance and access in the FUTURE (after the transaction): 6. Does the Applicant have in place formal Product Recall Plans? Yes No Describe formal plans for handling FUTURE (after the transaction) customer claims, communications and complaints, and product recalls. Attach copies of programs or explain below. 7. Any products ever recalled, withdrawn or suspended from use (voluntarily or involuntarily) Yes No due to actual or potential defects or safety reasons, including provisions of information or material for retro fitting? If yes, describe recall / retro fit actions and percent of products actually recovered / retro fit: Page 8 of 14

9 8. Describe formal plans for handling FUTURE (after the transaction) maintenance, repair, service and warranty work: LOSS EXPERIENCE Please explain all answers as requested. Include separate attachments as necessary. 1. Is the Applicant aware of any circumstances, injuries or offenses that might lead to a claim Yes No or suit being filed, including losses arising out of discontinued, divested or sold businesses or operations, or products no longer manufactured or sold? _ 2. Any judgments or settlements that are sealed or not disclosed within this Application? Yes No _ 3. Any current or past administrative, civil or criminal investigation or litigation by any Yes No governmental or regulatory authority? _ 4. Describe any individual claims and losses greater than U.S.A. 10,000. Include the date and nature of loss and amounts reserved and paid (including amounts within any deductible/retention and loss adjustment/defense expenses) and the current status (closed or open). Include separate attachments as necessary. LOSS EXPERIENCE SCHEDULES Provide aggregate loss experience in the Loss Experience Schedules for each year of the Injury or Offense Period or the last 10 years, whichever is greater. Include amounts within any deductibles/retentions and loss adjustment/defense expenses. Attach loss reports from prior insurers YEAR CLAIMS/LOSSES COUNT AMOUNT RESERVED AMOUNT PAID TOTAL INCURRED Page 9 of 14

10 OTHER LOSS EXPERIENCE - Please explain. Include auto liability, employer s liability and other loss experience if requesting excess liability insurance for such other exposures. FINANCIAL / TRANSACTION INFORMATION 1. Attach copies of audited financial statements and other pertinent financial information for the most recent year and each year of the Injury or Offense Period. 2. Describe any businesses, operations and products not consolidated within the financial information submitted that the Applicant is currently or has been involved with (including any contract work, investments, joint ventures, partnerships, etc.). Include separate attachments as necessary. 3. As part of this Application, please attach copies of: Purchase/sale/acquisition/merger transaction agreements, including all schedules, exhibits and disclosure statements Letters of intent, prospectus, side agreements and letters relating to the transaction PRIOR INSURANCE INFORMATION Attach copies of policies, including endorsements. Policy Period Insurer Premium Limits Deductible/Retention Any prior coverage on a claims-made basis? Yes No If yes, describe (including Retroactive Dates and status of Extended Reporting Periods): Page 10 of 14

11 ANY CLAIMS ARISING OUT OF CIRCUMSTANCES KNOWN TO YOU (WHICH OTHERWISE WOULD BE LIKELY TO GIVE RISE TO A CLAIM UNDER THE PROPOSED INSURANCE) ARE EXCLUDED FROM COVERAGE UNDER ANY EVENTUAL INSURANCE WE MAY PROVIDE. COMPLETION OF THIS APPLICATION DOES NOT BIND COVERAGE. APPLICANT S ACCEPTANCE OF THE COMPANY S QUOTATION IS REQUIRED PRIOR TO BINDING COVERAGE AND POLICY ISSUANCE. CERTIFICATION The undersigned persons declare that to the best of their knowledge the statements set forth above and in any attachments to this APPLICATION are true and correct, and that every reasonable effort has been made to obtain sufficient information to facilitate the proper and accurate completion of this APPLICATION. The undersigned agree that if any significant change in the condition of the Applicant is discovered between the date of this APPLICATION and the effective date of the policy which would render this APPLICATION inaccurate or incomplete, notice of such change will be reported in writing to the COMPANY immediately and, if necessary, any outstanding quotation may be modified or withdrawn. The undersigned persons understand and further agree that the completion and signing of this APPLICATION neither binds the COMPANY to sell nor the Applicant to purchase the insurance. PLEASE NOTE: ONLY DULY APPOINTED AGENTS OF THE COMPANY AND LICENSED BROKERS ARE AUTHORIZED TO SOLICIT APPLICATIONS FOR COVERAGE. AGENTS AND BROKERS ARE NOT AUTHORIZED TO BIND COVERAGE. NO COVERAGE SHALL BE PROVIDED UNLESS THE COMPANY ACCEPTS THE APPLICATION AND BINDS THE COVERAGE. False Information: Any person who, knowingly and with intent to defraud an insurance company or other person, files an Application for insurance containing any false information, or conceals for the purpose of misleading, information concerning any material fact thereto, commits a fraudulent insurance act, which is a crime. False Information (California Only): For your protection, California law requires the following to appear on this form: Any person who knowingly presents false or fraudulent claim for the payment of a loss is guilty of a crime and may be subject to fines and confinement in state prison. False Information (Colorado Only): 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 policyholder or claimant for the purpose of defrauding or attempting to defraud the policyholder 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. False Information (Florida Only): 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. False Information (Louisiana Only): 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. False Information (Maine Only): 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. Page 11 of 14

12 False Information (Nebraska Only): Any person who, knowingly and with intent to defraud any insurance company or other person, files an Application for insurance containing any false information, or conceals for the purpose of misleading, information concerning any material fact thereto, commits a fraudulent insurance act, which is a crime, where such person subsequently submits a claim. False Information (New Mexico Only): 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 civil fines and criminal penalties. False Information (New York Only): Any person who, knowingly and with intent to defraud any insurance company or other person, files an Application for insurance containing any materially false information, or conceals information concerning any material fact thereto, for the purpose of misleading, 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. False Information (Ohio Only): Any person who, with the 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. False Information (Oklahoma Only): 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. False Information (Oregon Only): Any person who, knowingly and with intent to defraud any insurance company or other person, files an Application for insurance containing any false information, or conceals for the purpose of misleading information containing any material fact thereto, may be guilty of a insurance fraud. False Information (Pennsylvania Only): 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 material fact thereto, commits a fraudulent insurance act, which is a crime and subjects such person to criminal and civil penalties. False Information (Vermont Only): Any person who, knowingly and with intent to defraud any insurance company or other person, files an Application for insurance containing any false information, or conceals for the purpose of misleading, information concerning any material fact thereto, commits a fraudulent insurance act, and the policy may be voided. False Information (Virginia Only): It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the purpose of defrauding the insurance company. Penalties include imprisonment, fines, and denial of insurance benefits. Applicant's Name/Legal Representative (print) Title Applicant Signature Date Producer Name (print) Title Producer Signature Date Page 12 of 14

13 Excess Liability Insurance Schedules Of Underlying Insurance If requesting Excess Liability Insurance, please complete copies of this Schedule for EACH year of the Injury or Offense Period. Attach additional Schedules as necessary. YEAR Describe Others Prem/Ops Liability Products/C.O. Liability Pers./Adv. Liability Auto Liability Employer's Liability Insurer Policy No. Policy Period Annual Premium Type Occurrence Claims-Made Occurrence Claims-Made Occurrence Claims-Made Occurrence Claims-Made Occurrence Claims-Made Retro Date ERP? Limits Of Insurance Occurrence per loc/project: Y/N Occurrence Accident Deductible/ Retention Claim / Event Claim / Event Claim / Event Please explain all answers as requested. Include separate attachments as necessary. 1. Defense/supplementary payments reduce any limits of insurance? Yes No If yes, describe: 2. Any coverage extensions: pollution, product recall, etc.? Yes No If yes, describe: Attach copies of all proposed underlying policies, including endorsements. Page 13 of 14

14 Excess Liability Insurance Autos Schedule If requesting Excess Liability Insurance for Auto Liability, please complete this Schedule. List number of units for each year of the Injury or Offense Period. TYPE OF UNIT / YEAR Private Passenger Light Trucks Medium Trucks Heavy Trucks Extra Heavy Trucks/Tractors Buses Other, describe TOTAL Please explain all answers as requested. Include separate attachments as necessary. 1. Caustics, explosives, flammables, waste or other hazardous materials transported? Yes No 2. Passengers transported for a fee? Yes No 3. Any drivers not covered by Workers Compensation insurance? Yes No 4. Any auto liability assumed under contract? Yes No w:/gl/liability Applications/Continuum Appl Updated with Fraud 2006.doc Page 14 of 14