Product Liability Application

PRODUCT LIABILITY APPLICATION FOR MEDICAL PRODUCTS

DISTRIBUTORS

Applicant Instructions: Application must be signed by owner, partner or officer. This application shall be attached to and become part of any insurance policy issued.

APPLICANT

A. Full name of all entities to be insured:______________________________________________________

B. Principal address:____________________________________________________________________

C. Phone#:_____________________________ Fax#:______________________________

D. r Individual r Partnership r Joint Venture r Limited Partnership r Other ___________

E. Years in business under present name:_____________________________________________________

F. Describe present or prior affiliation with other firms:___________________________________________

G. Proposed effective date for this insurance:__________________________________________________

FEIN: _______________________________ Website: _______________________________________

CONTACT NAME: ___________________________________________________________________

PRODUCTS

A. List all products you distribute. For each product, list whether you are (I) Importer, (W) Wholesaler, (MR) Manufacturers Representative, (D) Distributor. List who you sell to: (W) Wholesaler, (MR) Manufacturers Representative, (R) Retailer, (C) Direct to Consumer.

Product Gross Sales You Are You Sell To

(Est. This Yr.)

________________________ _______________ ____________ _______________

B. Gross Sales: Last Year_______________________ Preceding Year _______________

C. Have you discontinued or are you considering discontinuing any product to be covered by this insurance? r Yes r No

If Yes, please describe fully:___________________________________________________________

D. With respect to each product

1. Do you manufacture completed products? r Yes r No

2. Do you import component parts? r Yes r No

3. Do you export products or have foreign operations? r Yes r No

4. Are any of your products subject to regulation by any government agency? r Yes r No

Explain any “yes” answer to 2, 3 or 4 above:____________________________________________

_________________________________________________________________________________

E. Do you service, maintain or repair any products? r Yes r No

If yes, please explain and attach copies of contracts if applicable:________________________________

_________________________________________________________________________________

F. Do you obtain hold harmless or indemnity agreements from

dealers, suppliers or manufacturers? r Yes r No

Please attach copies

G. Do you require certificates evidencing Products Liability Insurance from

dealers, suppliers or manufacturers? r Yes r No

Please attach copies

PROCESSING AND QUALITY CONTROL

A. 1. Do others manufacture, assemble, package or install products under

your name or label? r Yes r No

2. Do you manufacture, assemble, package or install products for others

under their name or label? r Yes r No

Please explain any “yes” answer to A. 1. or 2. above:_________________________________

_________________________________________________________________________________

PROFESSIONAL LIABILITY

A. 1. Do you employ any professionals, or give medical advice? r Yes r No

2. Do you assist in, or train others in, the use of any surgical products? r Yes r No

3. Do you assist surgeons in operating room procedures? r Yes r No

CLAIMS HISTORY (attach company loss runs)

A. Please list all claims during the past five (5) years:

Policy Period Total Amounts Paid Total Amounts Reserved

___________________ __________________ _____________________

___________________ __________________ _____________________ ___________________ __________________ _____________________

B. Describe, in detail, any claim in excess of $10,000:___________________________________________

_________________________________________________________________________________

C. Are you aware of any circumstance, which may result in a claim or suit being brought or made against the applicant or any of your employees? r Yes r No

If yes, please describe:_______________________________________________________________

_________________________________________________________________________________

INSURANCE

A. Please indicate prior insurance carried:

Year Company Deductible/SIR Limit Carried Premium

___________ ____________________ ________________ _______________ _________

B. Is your current coverage r Claims Made or r Occurrence

If you have ever carried a “Claims Made” policy please provide Retro Date:_______________

C. Insurance requested:

1. Limit of Liability:______________________________________

2. Deductible/SIR:_______________________________________

D. Has an insurer ever canceled or refused to renew your Products Liability

Insurance? r Yes r No

If yes, please explain:_________________________________________________________________

_________________________________________________________________________________

Please attach Brochures, Labels, Service Agreements etc.

Any person who knowingly 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 also punishable by civil penalties in certain jurisdictions.

If you have any questions about the form or your answers, please ask a sales representative before completing the form.

The questions in this application are not intended to, nor do they, indicate the existence, non-existence or limitations on any items of coverage. This document does not in any way determine coverage provided.

Signature and Attestation: Name (Print): ______________________________

Return To: Signature: _________________________________

VGM Insurance Title: _____________________________________

A Division of DME Association, Inc. Date: _________/_________/_________

Rev.060807

Please Print, fill in your information, then fax to Leon P Williams: Fax: 636-537-5076