General Information

I. AGENT/BROKER
II. PREMISES
III. OPERATIONS

Annual Advertising Expenditure

Estimated 20_ 20__ 20__ 20__
Annual Advertising Expenditure
Annual Sales
Annual Gross Receipts
Annual Payroll
No. of Employees (Excluding Shipboard)
No. of Employees (Including Shipboard)
Annual Throughput (if applicable)
LIABILITY EXPOSURES
Insurance Limit Premium Payroll
Longshoremen's Harborworker's Act
Federal Railroad Employees Act
Admiralty or Jones Act
Vessel Year Built Dimensions GRT No of Crew
IV. INSURANCE DETAILS
Carrier Policy Type Limit Aggregate Annual Premium
Date of Loss Claimant Policy Type Paid Claim Outstanding Claims Description of Loss
Each Person Each Accident Annual Aggregate
Property Damage
Bodily Injury

PRODUCT LIABILITY QUESTIONNAIRE

Name & Description Manufacturer or Distributor Years on the Market Expected Life How Sold (Bulk, Pkg, etc.) Annual Sales($) Annual Sales Units
%

LOSS HISTORY (PLEASE ATTACH FIVE YEAR HARD COPY LOSS RUNS IF AVAILABLE)

I understand that the above information and supplemental information enclosed, which is correct to the best of my knowledge, is to be the basis of insurance if a policy is issued, but does not obligate the Applicant to accept the insurance nor oblige the insurer to effect insurance on the risk.

Berkley

Cookie Settings

Cookies are small text files that are stored in your browser when you visit some websites.

Cookies are used for numerous purposes. This website utilises two categories of cookie as defined by the International Chamber of Commerce guide for cookie categories:

  • 'Strictly Necessary Cookies' that are required for the website to function at a basic level.
  • 'Performance Cookies' that are used to collect anonymous user behaviour data which are used to further improve the site,

By default all cookies are active on this website to provide the best user experience. However, if you prefer to deactivate certain categories of cookie you can set your preference below.

Cookie Preference Options
Core Functionality Strictly Necessary Anonymous Website Usage Tracking Performance

This website allows visitors to manage the cookies that are used, however reducing cookie usage may degrade the user experience. Please note that this cookie management tool requires JavaScript to be supported in your browser, otherwise you will need to manage cookies through bowser settings.

Cookies will only be read or written for the preference level set, however, cookies that have been set prior to setting a lower level of cookie usage will remain on your computer. You can remove these cookies through your browser settings.

A cookie is used to remember your cookie preference. Therefore if you delete all of your cookies, use a different machine, user profile or browser then your preference will not be available to this tool and you will need to select your preference again.

Cookie Schedule

STRICTLY NECESSARY COOKIES
_cmp Holds user cookie preferences Persistent This Domain
Performance Cookies
_utma Google Analytics Persistent This Domain
_utmbGoogle AnalyticsPersistentThis Domain
_utmc Google Analytics Session This Domain
_utmz Google Analytics Persistent This Domain
Cookie Details Cookie Settings
Cancel Save & Close