Bicycle Manufacturers Product Liability Application

Applicant Information

Principal Location Address- Street
City State
Postal Code Country
List all other locations:
* *
Contact's Mailing Address- Street
City State
Postal Code Country

Product Information

Estimate for the upcoming year:

Worldwide Coverage Territory Endorsement desired? (Note: This is NOT foreign liability)

Please show sales and payroll for the last five years.

Enter Year / Sales ($) / Payroll ($)

Only those products and services specified below will be considered for coverage: (Use additional pages if needed)

Who do you sell to? (Choose All That Apply)
Who do you sell to? (Choose All That Apply)
Who do you sell to? (Choose All That Apply)

If you sell additional products, please enter information below, including Product Name/Number of years in Market / Gross sales next 12 months ($)

Additional product info
Who do you sell to? (Choose all that apply)
Retroactive Date (if applicable)
Are all exposures indicated on website reflected on applications?
If "NO", provide detail
Describe your products & services
Insured's product is:
Intended use(s) and final users of the insured's product(s) are:
Any products acquired via acquisition or merger?
Did you assume liability for these products?
If "YES", please describe and indicate sales of those products:
List any discontinued products your insured has manufactured or sold. (If None, specify NONE)
If discontinued products exist, was a separate general liability policy purchased to cover them?
Have you ceased manufacturing products during the last five years?
If "Yes," please describe and indicate sales of those products:
Do the insured's products have an identifying logo, name and/or serial number on them?
List locations where products are manufactured or assembled:
Do you manufacture the complete product?
If "No," what component parts are purchased by you?
Where are the component parts manufactured?
Do you or have you ever taken used equipment and refurbished it for resale?
If "Yes," types of equipment:
Do you or your subcontractors install any of your products?
If "Yes," please describe and indicate which products:
If "Yes," is the installation performed at the customer's location?

Loss Prevention/Product Design/Quality Control

List any quality measurement standards for which you are certified (examples: ISO 9000, ASME, UL):
List any memberships in any industry product-standard associations:
Have your products ever been subject to inquiry or investigation relative to product safety by any governmental agency? (If "Yes," please attach details)
Do you have a written products recall plan? (If "Yes," please attach a copy.)
Is there recall insurance?
Have you ever recalled products because of a potential product safety hazard? (If "Yes," attach details indicating percent of recovery.)
Do you do your own design work?
Are your designs subject to independent external review, testing or certification? (If "Yes," attach details and dates.)
Are your products designed, tested, labeled and manufactured tomeet or exceed all government and industry standards?
Are written testing procedures followed?
Are supplies and components ordered to your specifications?
Have you determined which supplies and components are critical to the safety of your final product?
List all critical supplies and components items, indicating whether testing is on a sample basis or on all units:
Are warranties obtained from all suppliers?

Instructions/Warnings/Loss Control/Defense

Are instructions, warning labels and advertising texts provided to your customers?
Are all warning labels and instruction/operating manuals reviewed by legal counsel prior to use?
Do you provide any specific training/instruction for the ultimate user in the proper use of your product?
If YES, please describe:
Explain how you identify your products and parts from similar competitors' products and parts:

Can you determine, based on available records for ALL products you have sold:

When any given product item was manufactured?
To whom it was sold, and the date of sale?
Who supplied parts and supplies going into the final product?
Do you have a written procedure for obtaining information about product complaints, accidents and injuries involving your product(s)?
Does your procedure provide for examining and preserving any allegedly defective product, with the results of such examination record?
Do you issue guarantees and/or warranties to purchasers?
If "Yes," please describe what period do you guarantee your products:
Has insurance been canceled or non-renewed in the past year for non-compliance of recommendations or any other reason?
If "Yes," please describe circumstances:
Has applicant filed Bankruptcy (Chapter 7, 11 or 13) or is applicant in receivership?

Claims History

5 years or more (attach hard copy from prior carriers)

Total aggregate losses, from the first dollar, including expenses, including all information listed below:

Date Carrier Policy Period No. of Claims Total Amounts Paid Amount Reserved Total Incurred
Indemnity ($) Expense ($)  Indemnity ($) Expense ($)