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.