Toy Insurance



Application Form


中的应用


Application for Products Liability
email: jawelch@york-jersey.com
732-842-2012

Applicant's Instructions:
  1. Answer all questions completely. Application must be signed and dated by owner, partner, or officer not earlier than 45 days before proposed effective date of coverage.
  2. Please read the statements at the end of this application carefully. Thank you.
  3. Make sure you complete all fields before submitting. Click on Submit when ready to send.

Applicant Name:
Title:
Company Name:
Address:
City, State, Zip:
Email Address:
Date:

1. Give the full name of the applicant and subsidiary companies and operations of each:


2. Principal Address:


3. Website Address:

4. Type of business: Corporation:    Partnership:    Proprietorship:
Other: (Please specify)

5. Sales/Receipts estimate for the next 12 months:
USA & CANADA: $   REST OF THE WORLD: $

5a. Please list the countries you are selling to other than the USA & Canada:


6. Limits of liability required: $

6a. What day would you like the policy effective?

7. How many years has applicant been in business under the current name?:

8. Have any of the principals ever engaged in this or similar enterprises under a different name?:    Yes    No    (if yes, provide details)


9. Please state the name, title and telephone number of the person we may contact in order to arrange for an inspection of your operation:
Name:
Title:
Telephone #:

PRODUCTS AND SERVICES

10. Describe the products and services of the applicant and show the number of years each product or service has been offered:


11. Do you sell to TOYS 'R' US or any division of TRU?    Yes    No

11a. Give the name/industry of the three largest customers:
a:
b:
c:

12. Who performs the installation of the applicant's product(s)?:
Applicant    Third Party hired by Applicant   
Customer   Third Party hired by Customer
(if more than one method used, please explain)

13. What products have you ceased manufacturing during the past ten (10) years?:
Provide details or state "none" if none applies.

14. Does applicant retain the liability for any products or operations which they no longer control?:    Yes    No (If yes, please explain)


15a. Have any products been acquired by merger or acquisition?:    Yes    No
(if so, please explain)

15b. Did the applicant assume liability of these products?:    Yes    No
(If so, please explain)


16. Sales in the last three years:
  U.S. Canada Rest of World
Sales Estimate:
First prior year:
Second prior year:
Third prior year:
Fourth prior year:
Fifth prior year:


Product
Description
Years
in
Market
Estimated
Product
Life
% of
Gross Sales
M / W / R
I / MR
Products
Sold To
M / W / R
I / C / O
Does
Applicant
(I) Install or
(R) Repair
M = Manufacturer R = Retailer MR = Manufacturer Rep. O = Other
W = Wholesaler I = Importer C = Consumer - direct  


17. Will any new products be introduced in the new 12 months?:    Yes    No
(If yes, please explain)


18. Do you import products or component parts?:    Yes    No
(If yes, please explain)


19. Have you ever recalled products?    Yes    No  (If yes, please explain)


20. Have any of your products ever been subject to injury or investigation relative to product safety by a governmental agency?:    Yes    No  (If yes, please explain)


21. How can your products be identified from the products of your competitors?:


22. Describe materials or principal components of each product:
a:
b:
c:

23. Do you design and manufacture the complete product?:    Yes    No
If no, what components are purchased by you?: (Please describe)


24. Is the product under your label?:    Yes    No
If yes, what is the process?: (Please describe)


25. Do you maintain and/or service the products?:    Yes    No
(Please provide details)


26. Do you maintain quality control procedures?:    Yes    No
(If yes, describe details of these procedures)


27. Do you maintain complete inventory records of shipments and/or delivery to consignees?:    Yes    No

(If yes, are serial and/or batch numbers shown on the finished product and on shipment invoices?)    Yes    No

28. Can the date of manufacture of each product be identified by the factory numbers stamped on it?:    Yes    No

29. Do you keep samples of products involved in your quality control procedures?:
   Yes    No (If yes, how long?)


30. Do you have a formal "Products Recall Plan"?:    Yes    No

31. Do you have a written procedure for the handling of complaints about your products and accidents/injuries involving your products?:    Yes    No
(If yes, please provide details)


32. Is a written record of all such complaints, accidents, injuries maintained?:
   Yes    No

Who is the individual or the department responsible to maintain these records?:


33. Is any component in your product(s) considered as a "hazardous substance" under any government regulations?:    Yes    No

If yes, provide descriptions and names of these substances.


34. If you are a distributor and do not actually manufacture the products you sell, then does your manufacturer(s) provide you with vendors liability coverage?:
   Yes    No

35. Please let us know if you would be interested in receiving quotes for any of the following coverage:
a. Workers Compensation e. Foreign Travel
b. Ocean Cargo f. Intellectual Property
c. Property g. Health
d. Commercial Automobile h. Other - Type:


PRIOR INSURANCE


36. Who was your insurer in the last 3 years?: (if self-insured, so state)


37. State limit of liability, SIR or deductible (specify which), retroactive date (if any), rate and premium:
Year Carrier limit DEC/SIR: Rate/Premium

38. If you have been self-insured or had an SIR, who adjusted the claims and established reserves?:


39. Has any carrier cancelled, restricted or refused to renew your products liability insurance in the past five years?:    Yes    No    (If yes, please explain)


40. Are any of your products intended for use on or in connection with:
Aircraft or missiles? Yes    No
Watercraft? Yes    No
Offshore operations? Yes    No

41. Do you require certificates of insurance from your suppliers?:    Yes    No    (If yes, indicate minimum limit acceptable)


42. Do you provide insurance to your distributor?:    Yes    No    (If so, explain)


43. Are your products designed, tested, labeled and manufactured to meet or exceed all industry of government standards?:    Yes    No    (If no, please explain)



PRODUCTS LIABILITY CLAIM HISTORY


44. Please provide at least five years data on claims-both total losses from first dollar, including expenses and specific date on individual losses paid or reserved for $10,000 or more (first dollar including expenses)

A hard copy of these loses from prior carriers may be required.

(loss amounts must be from first dollar and include expenses)

Policy Period Carrier Number of Claims Amounts Paid Reserved Date Losses Valued

45. How did you hear about us?


PLEASE CHECK TO ENSURE THAT ALL QUESTIONS HAVE BEEN ANSWERED

Copies of the following may be required:
  • Product brochures/catalogs
  • Last annual financial statement for applicants with revenues of $5,000,000 and higher
Also attach explanation to questions which may be useful.

Submitting this agreement indicates your acceptance of its terms.

Applicant’s Digital Signature: (Please type name)
Company Email:

  


NOTICE TO APPLICANTS: The coverage applied for is solely as stated in the policy. If policy is issued on a "CLAIMS MADE" or "CLAIMS MADE AND REPORTED" basis, it provides coverage only for those claims that are first made against the insured during the policy period unless the extended reporting period option is exercised in accordance with the terms of the policy. If issued on an "OCCURRENCE" basis, the policy provides coverage only for those occurrences that take place during the policy period.

The Insurer will rely upon this application and all such attachments in issuing the policy. If the information in this application or any attachment materially changes between the date this application is signed and the effective date of the policy, the Applicant will promptly notify the Insurer, who may modify or withdraw any outstanding quotation or agreement to bind coverage.

In New York: 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 fact material thereto, 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.

In all other states; it is a crime for any person to knowingly provide or facilitate in providing any false, incomplete, or misleading information to an insurance company. Penalties may include fines, imprisonment and denial of insurance benefits.

WARRANTY: I warrant to the Insurer, that I understand and accept the notice state above and that the information contained herein is true and that it shall be the basis of the policy of insurance and deemed incorporated therein, should the Insurer evidence its acceptance of this application by issuance of a policy. I authorize the release of claim information from any prior insurer to York-Jersey Underwriters, Inc., 185 Newman Springs Road, Tinton Falls, NJ 07724.

Other Key Services

Auto/Home

York-Jersey Underwriters represents 15 auto and homeowner insurers. We always provide multiple quotes from a variety of companies to ensure you are receiving the best service and highest value. You can be assured that your independent agent has your best interests in mind.

Business

From Wall Street to Main Street, we insure businesses of all sizes. Whether you are a retailer, wholesaler, contractor or manufacturer, we have the expertise to tailor your coverage plans to meet your particular needs. By representing many of the leading national and regional insurance companies, we can design a comprehensive protection plan that works for your bottom line.

Life/Health Employee Benefits

York Jersey Underwriters also specializes in employee benefits. Our organization has a team of employee benefit specialists who have over 30 years of combined experience with group benefits. Our employee benefit specialists focus on reducing employer cost without decreasing employee benefits.

Mortgage Field Services

York-Jersey Underwriters has insured the mortgage field service industry since 1983 and has the endorsement of the National Association of Mortgage Field Services (NAMFS). This is the oldest, largest and only not-for-profit field service association in the country.